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Revision History The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 2
Revision Date: April 2011
Version 3.9
Revision History The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 3
Revision Date: April 2011
Version 3.9
Revision History
Version
Revision Date
Revision Page Number(s)
Reason
Reviser
2.0
Feb. 2005
All
Annual revision
Publications
2.1
March 2005
8-15
Added Acronyms
Publications
3.0
June 2005
64, 65, 121, 151 - 154
Redaction
Publications
3.1
Oct. 2005
127
Redaction
Publications
3.2
Jan. 2007
All
2006 annual update
Publications
3.3
Aug. 2007
All
2007 annual update
Publications
3.4
Dec. 2007
All
Redaction
Publications
3.5
July 2008
54 – 57
CO 8766 - Redaction
Publications
3.6
Oct. 2008
178 - 182
OHCA ordered
Publications
3.7
Dec. 2008
26 – 38, 313
Medical Home updates
Publications
3.8
Feb. 2011
74, 77, 82, 89, 90, 95
Redaction
Publications
3.9
April 2011
91
Redaction
Publications Revision History The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 4
Revision Date: April 2011
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Table of Contents The OHCA Provider Billing And Procedure Manual
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Table of Contents
Chapter 1 General Information ............................................................... 9
Introduction ............................................................................................... 10
Section A: OHCA Web site ..................................................................... 10
Section B: General Contact Information: ................................................. 12
Chapter 2 SoonerCare Programs .......................................................... 15
Introduction ............................................................................................... 16
Section A: Provider Policies .................................................................... 16
Section B: Provider File Maintenance ...................................................... 17
Section C: Provider Services .................................................................... 17
Section D: Written Inquiries .................................................................... 23
Chapter 3 SoonerCare Choice ............................................................... 24
Introduction ............................................................................................... 25
Section A: Covered Members .................................................................. 26
Section B: Access to Care ........................................................................ 27
Section C: Member Enrollment/Disenrollment ....................................... 28
Section D: Referrals ................................................................................. 30
Section E: EPSDT .................................................................................... 32
Section F: Reporting Requirements ......................................................... 33
Section G: Reimbursement ....................................................................... 33
Section H: Provider Resources ................................................................ 34
Chapter 4 Member Eligibility Verification .......................................... 37
Introduction ............................................................................................... 38
Section A: Member ID Card ..................................................................... 38
Section B: Options to Verify Member Eligibility ..................................... 38
Chapter 5 Web/RAS ............................................................................... 42
Introduction ............................................................................................... 43
Section A: Accessing The Secure Web Site ............................................ 43
Section B: Web Features .......................................................................... 48
Section C: Remote Access Server (RAS) ................................................ 59
Chapter 6 Claim Completion ................................................................. 67
Introduction ............................................................................................... 68
Section A: Paper Claim Recommendations .............................................. 68
Section B: 1500, Professional, 837P ......................................................... 70
Section C: UB 04, Institutional, 837I........................................................ 84
Section D: ADA 2006, Dental, 837D ....................................................... 97
Section E: Drug/Compound Prescription Drug , Pharmacy, NCPDP .... 107
Section F: Electronic Claim Filing Attachment Filing ........................... 116
Section G: Medicare-Medicaid Crossover Invoice ................................. 118
Chapter 7 Electronic Data Interchange ............................................. 121
Introduction ............................................................................................. 122
Section A: Professional Claims (837 Professional) ............................... 123
Section B: Institutional Claims (837 Institutional) ................................ 124
Section C: Dental Claim (837 Dental) ................................................... 124
Section D: Pharmacy Claims .................................................................. 125
Section E: Claim Inquiries/Responses .................................................... 125 Table of Contents The OHCA Provider Billing And Procedure Manual
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Section F: Eligibility Inquiries/Responses .............................................. 126
Section G: Remittance Advice (RA)....................................................... 127
Section H: Electronic Claims or Prior Authorizations with Paper Attachments ............................................................................................ 127
Section I: Electronic Media Types .......................................................... 128
Section J: HIPAA transaction and code set requirements ..................... 129
Chapter 8 Claims Resolution Process ................................................. 130
Introduction ............................................................................................. 131
Section A: Claim Creation ..................................................................... 131
Section B: Data Entry ............................................................................ 132
Section C: Resolutions ........................................................................... 133
Chapter 9 Paid Claim Adjustment Procedures.................................. 136
Introduction ............................................................................................. 137
Section A: Adjustment Categories .......................................................... 137
Section B: Adjustment Types and Workflow ........................................ 140
Chapter 10 Indian Health Services ..................................................... 141
Introduction ............................................................................................. 142
Section A: SoonerCare Eligibility .......................................................... 142
Section B: Contract Health Services ....................................................... 142
Chapter 11 Pharmacy ........................................................................... 143
Introduction ............................................................................................. 144
Chapter 12 Insure Oklahoma .............................................................. 147
Introduction ............................................................................................. 148
Section A: What is the Insure Oklahoma Individual Plan? ................... 148
Section B: Insure Oklahoma Individual Plan Billing Procedures .......... 150
Chapter 13 Long Term Care Nursing Facilities ............................... 151
Introduction ............................................................................................. 152
Section A: LTC Nursing Facility Provider Eligibility ............................ 152
Section B: Pre-admission Screening And Resident Review Process (PASRR) ................................................................................................. 152
Section C: ICF/MR Process .................................................................... 152
Section D: Member Level Of Care Appeals Process .............................. 153
Section E: Billing Considerations ........................................................... 153
Chapter 14 Third Party Liability ........................................................ 154
Introduction ............................................................................................. 155
Section A: Services Exempt from Third Party ....................................... 157
Section B: Third Party Liability Claim Processing Requirements ......... 158
Section C: Coordination with Commercial Plans ................................... 161
Section D: Medicare-OHCA Related Reimbursement ........................... 162
Section E: Member Third Party Liability Update Procedures ................ 164
Chapter 15 Prior Authorization .......................................................... 168
Introduction ............................................................................................. 169
Section A: Prior Authorization Requests ............................................... 169
Section B: Prior Authorization Process .................................................. 171
Section C: Reconsideration and Appeal Procedures .............................. 172
Section D: Home & Community-Based Services (HCBS) §1915(c) WAIVER Prior Authorizations ............................................................... 174 Table of Contents The OHCA Provider Billing And Procedure Manual
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Chapter 16 Financial Services ............................................................. 175
Introduction ............................................................................................. 176
Section A: Payment Information ........................................................... 176
Section B: Paper RA .............................................................................. 177
Section C: Electronic Remittance Advice .............................................. 303
Section D: 1099 & W-2s ........................................................................ 303
Section E: Stop Payments, Voids, Re-issuance ..................................... 303
Section F: Electronic Care Coordination Payments ............................... 304
Chapter 17 Utilization Review ............................................................. 309
Introduction ............................................................................................. 310
Section A: Provider Utilization Review ................................................ 311
Section B: Member Utilization Review ................................................. 312
Section C: Utilization Review Trends ................................................... 313
Section D: Administrative Review and Appeal Process ........................ 314
Chapter 18 Quality Assurance And Improvement ........................... 315
Introduction ............................................................................................. 316
Section A: Provider Utilization Review ................................................ 316
Section B: On-Site Provider Audits ....................................................... 317
Section C: Member or Provider Complaints .......................................... 318
Section D: Quality Improvement Studies/Projects ................................ 318
Section E: System Integrity ................................................................... 319
Chapter 19 Forms ................................................................................. 321
Introduction ............................................................................................. 322
Table of Contents The OHCA Provider Billing And Procedure Manual
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Chapter 1: General Information The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 9
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Provider Billing And Procedure Manual Chapter 1: General Information The OHCA Provider Billing And Procedure Manual
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Revision Date: April 2011
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INTRODUCTION
The Oklahoma Health Care Authority (OHCA) is the state agency responsible for the administration of the Oklahoma Medicaid program. The OHCA has a contractual agreement with Electronic Data Systems (EDS) to be the fiscal agent for the Oklahoma Medicaid program. The OHCA‟s primary objective is to maintain a system to accurately and effectively process and pay all valid Oklahoma Title XIX Medicaid program provider claims.
This publication is the primary reference for submitting and processing claims, prior authorization requests, remittance advice and other related documents. This manual is not a legal description of all aspects of Medicaid law. This manual is intended to provide basic program guidelines for providers that participate in the Oklahoma Medicaid program.
A provider‟s participation in the Oklahoma Medicaid program is voluntary. However, providers that chose to participate in Medicaid must accept the Medicaid payment as payment in full for services covered by Medicaid. The provider is restricted from charging the Medicaid member the difference between the usual and customary charge, and Medicaid‟s payment. Services not covered under the Medicaid program can be billed directly to the member. If there are any instances where the guidelines appear to contradict relevant provisions of the Oklahoma Medicaid policies and rules, the policies and rules will prevail. This manual does not take precedence over federal regulation, state statutes or administrative procedures. The OHCA and EDS developed this manual for Oklahoma Medicaid providers.
The Provider Billing And Procedure Manual will receive periodic reviews, changes and updates. The online version of this manual is the most current version and is available at the OHCA Web site at http://www.okhca.org. Once there, click on Provider, Policies & Rules, scroll down to Guides & Manuals and click on the OHCA Provider Billing & Procedure Manual. Providers issued print and CD copies of this manual will not automatically receive an updated version.
SECTION A: OHCA WEB SITE
The OHCA administers the state of Oklahoma‟s Medicaid agency program known as “SoonerCare.” Primary programs under SoonerCare include: SoonerCare Traditional, SoonerCare Choice and Sooner Plan. The OHCA Web site at http://www.okhca.org (see screen sample 1.1) provides information for Medicaid members and providers with data on programs, and health and medical policies. Chapter 1: General Information The OHCA Provider Billing And Procedure Manual
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Screen sample 1.1
OOHHCCAA WWEEBB PPAAGGEESS
Calendar: The Calendar page can be used to find dates and details on training, meeting and other upcoming events.
Contact Us: Use the Contact Us page to find everything from OHCA addresses and telephone numbers to driving directions to the OHCA office.
Provider: The Provider page has information on becoming a Medicaid provider, provider-type details, claim management tools, program reference resources, rule and policy data, free training opportunities, and updates on what is new in SoonerCare.
Publications: The Publications page has links to most OHCA publications, forms, and OHCA information on statistical reports and data. Chapter 1: General Information The OHCA Provider Billing And Procedure Manual
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SECTION B: GENERAL CONTACT INFORMATION:
OOHHCCAA CCaallll TTrreeee
Toll free: 800-522-0114, or in Oklahoma City area: 405-522-6205 Option Unit Call Types Availability 1 OHCA Call Center Claim status, eligibility inquiries or policy questions 7:30 am – 5:30 pm M-F
2, 1
Internet Help Desk
Internet PIN resets or assistance with Medicaid on the Web
8 am – noon & 1pm – 5 pm M-F 2, 2 EDI Help Desk Batch transactions assistance 8 am – noon & 1pm – 5 pm M-F
3, 1
Adjustments
Paid claim adjustments or outstanding A/R inquiries
7:30 am – 4 pm M, W, Th, F
12 p.m. – 4 p.m. Tues. (Training) 3, 2 Third Party Liability Health insurance injury/accident questionnaires, third party insurance inquiries, estate recovery or subrogation issues 8 am – 5 pm M-F 4 Pharmacy Help Desk (issues) Pharmacy issues 8:30 am – 7 pm M-F 9 am – 5 pm Sat. 11 am – 5 pm Sun. 5 Provider Contracts Provider contracts 8:30 am – 4:30 pm M, T, Th, F 12:00 pm- 4:30 pm Wed. (Training) 6, 1 Pharmacy Help Desk (authorizations) Pharmacy authorizations 8:30 am – 7 pm M-F 9 am – 5 pm Sat. 11 am – 5 pm Sun. 6, 2 Behavioral Health Authorization Behavioral Health authorizations 8 am – 5 pm M-F 6, 3 Medical Authorizations (status) Medical authorization status 7:30 am – 5:30 pm M-F 6, 4 Medical Authorizations (PA requests) Prior authorization requests for DME, medical services and emergency PAs for aliens 8 am – 5 pm M-F Closed 10 am – 1 pm Tue.
6, 5
Dental Authorizations
Dental authorizations
8 am – 5 pm M-F Chapter 1: General Information The OHCA Provider Billing And Procedure Manual
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CCLLAAIIMM MMAAIILLIINNGG AADDDDRREESSSS::
EDI Mail tapes, CDs and diskettes to: EDS P.O. Box 54400 OKC, OK 73154
Form UB-04 (Hospital or Home Health) Lab or DME (1500) EDS P.O. Box 18430 OKC, OK 73154
Form 1500 EDS P.O. Box 54740 OKC, OK 73154
HMO Co-pay/Personal Care (Individual; not agency) EDS P.O. Box 18500 OKC, OK 73154
Medicare Crossovers, Dental (ADA form), (1500) EDS P.O. Box 18110 OKC, OK 73154
Pharmacy EDS P.O. Box 18650 OKC, OK 73154
Waiver provider billing for waiver services P.O. Box 54016 OKC, OK 73154
Refunding money or returning check OHCA-Finance Unit P.O. Box 18299 OKC, OK 73154
Sending a written inquiry with copy of claim OHCA-Provider Services P.O. Box 18506 OKC, OK 73154
Long Term Care Nursing Facilities EDS P.O. Box 54200 OKC, OK 73154
Claim adjustment request OHCA-Adjustment Unit 4545 N.Lincoln Blvd Suite 124 OKC, OK 73105
Chapter 1: General Information The OHCA Provider Billing And Procedure Manual
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Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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Provider Billing And Procedure Provider Billing And Procedure Manual Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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INTRODUCTION
In order to be eligible to participate in Oklahoma SoonerCare programs, providers must have an approved provider agreement on file with the OHCA. Through this agreement, the provider certifies all information submitted on claims is accurate and complies with all applicable state and federal regulations. This agreement is effective once the provider signs the agreement, and the OHCA reviews and approves the agreement.
SECTION A: PROVIDER POLICIES
A provider is any individual or facility that qualifies and meets all state and federal requirements, and has a current agreement with the OHCA to provide health-care services under SoonerCare or other OHCA-administered medical service programs.
PPAAYYMMEENNTTSS
Payments to providers under SoonerCare are made for services identified as personally rendered services performed on behalf of a specific patient. There are no exceptions to personally rendered services unless specifically set out in coverage guidelines.
Payments are made on behalf of SoonerCare eligible individuals for services within the scope of the OHCA‟s medical programs. Services cannot be paid under SoonerCare for ineligible individuals, services not covered under the scope of medical programs or services not meeting documentation requirements. These claims will be denied or payment will be recouped, in some instances upon post-payment review.
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For additional information on provider policies, go to www.okhca.org, click on the Policies & Rules link (see Screen Sample 2.1). When the page appears, select the Oklahoma Health Care Authority Medical Rules link and select Chapter 30. Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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Screen Sample 2.1
SECTION B: PROVIDER FILE MAINTENANCE
Provider agreements must be renewed every three years. It is the responsibility of the provider to maintain records and agreements with the OHCA.
All information changes including address, phone number, bank (including electronic funds transfer data) and group member changes must be promptly reported. Failure to maintain current provider information can result in delay or denial of payments for services rendered. Changes for all provider record information should be in writing and signed by the provider. Please mail your request to:
Oklahoma Health Care Authority
Attention: Provider Enrollment
P.O. Box 54015
Oklahoma City, OK 73154
For additional information on provider enrollment criteria, call the OHCA toll-free in state at 800-522-0114 (option 5), or out of state at 405-522-6205 (option 5). You can also go to www.okhca.org, click on Enrollment, New Contracts and select the appropriate option.
SECTION C: PROVIDER SERVICES
EELLIIGGIIBBIILLIITTYY VVEERRIIFFIICCAATTIIOONN SSYYSSTTEEMM ((EEVVSS))
The EVS system is available from 5 to 1 a.m. Access information by entering the provider‟s SoonerCare ID number and the alpha-character location code. Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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The automated voice response (AVR) system provides a nationwide toll free telephone number to help providers obtain pertinent information. Providers are able to enter information on a touch-tone phone or by the AVR speech application.
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The following is a list of information that can be obtained through the AVR: Member eligibility with fax back capabilities. Provider warrant information. Prior authorization with fax back capabilities. Claim status inquiry.
More information regarding the EVS can be found in the Member Eligibility Verification chapter of this manual
EEVVSS PPhhoonnee NNuummbbeerrss
Nationwide toll free: 800-767-3949
Oklahoma City metro area: 405-840-0650
CCOOMMPPUUTTEERR TTEELLEEPPHHOONNYY IINNTTEEGGRRAATTIIOONN
Computer Telephony Integration (CTI) allows providers to enter information - such as name, provider number and location - through the AVR system. The information is captured and sent to the appropriate provider service coordinator. The provider representative enters notes and questions from the provider into the call tracking system, so if a call must be transferred the provider‟s information will be captured and available to the next representative.
CCAALLLL CCEENNTTEERRSS
The OHCA is committed to providing customer service to the provider community, members and other interested parties. OHCA Call Center representatives answer inquiries regarding claim status, eligibility, warrant information, proper billing procedures, prior authorization and SoonerCare policy for providers as well as members. Complex claims and written correspondence are some of the types of inquiries addressed by the OHCA Provider Service Coordinators.
OHCA Services closely interacts with the EDS Provider Relations staff to resolve training issues related to the Oklahoma SoonerCare program. Provider Services and EDS Provider Relations act as intermediaries for providers, members and others by resolving billing or adjudication problems requiring additional information or research.
PPRROOVVIIDDEERR IINNQQUUIIRRIIEESS
Telephone inquires are received between 7:30 a.m. and 5:30 p.m., Monday through Friday. (Pharmacy Help Desk is available extended hours seven days/week.) Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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AAvvaaiillaabbllee SSeerrvviicceess
Information available to the provider through the call tree options include: Claim status. Eligibility/EVS. Pharmacy Help Desk. Provider Contracts. Adjustments. Third Party Liability (TPL). PIN resets. Prior Authorization.
o Medical.
o Dental.
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When calling OHCA Provider Services or the OHCA Call Center, have the following information available to expedite the research of the inquiry:
 The 10-character (nine numbers, alpha character) SoonerCare provider number.
 The SoonerCare member‟s ID number.
 The date(s) of service.
 The billed amount.
MMEEMMBBEERRSS IINNQQUUIIRRIIEESS
When inquiring by telephone, please call between 7:30 a.m. and 5:30 p.m., Monday through Friday.
PPhhoonnee NNuummbbeerrss
Members toll-free: 800-522-0310
Metro Area: 405-522-7171
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Information available for the members through the call tree options include: Eligibility. Claim status. SoonerCare Member Services. Pharmacy Help Desk Enrollment Agent. Patient Advice Line, 5 p.m. – 8 a.m. M-F, 24 hours daily on holidays and weekends when Help Line is closed. Spanish assistance, 7:30a.m. – 5:30 p.m. M-F.
EEDDSS FFIIEELLDD CCOONNSSUULLTTAANNTTSS
EDS has a team of regional field consultants with in-depth knowledge of Oklahoma SoonerCare billing requirements and claim-processing procedures. Training is offered on billing, EVS Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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and AVR, Electronic Data Interchange (EDI) and Medicaid on the Web Secure Site. Field consultants provide training through on-site visits and workshops. They encourage providers to use electronic claim submission because it‟s fast, easy to use and saves money.
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The focus of a field consultant is to
1. train newly enrolled providers;
2. contact and visit high-volume providers; and
3. conduct provider training workshops.
Providers may contact their field consultant by telephone to request a visit for training at the provider‟s location. Field consultants are responsible for arranging their own schedules. They are available Tuesday through Thursday for onsite provider visits. Provider on-site visits are normally scheduled two weeks in advance. Since field consultants are often out of the office, please allow a minimum of 48 hours for telephone calls to be returned.
NOTE: Field consultants are the last resource for any claim inquiry questions. For claim research or resolution of other Oklahoma SoonerCare issues, contact the OHCA Call Center at 800-522-0114 or 405-522-6205.
PPrroovviiddeerr WWoorrkksshhooppss
Field consultants are responsible for the development and presentation of educational workshops about all procedural aspects of the Oklahoma Medicaid Management Information System (OKMMIS).
The OHCA presents scheduled workshops throughout the year to educate providers on Oklahoma SoonerCare claim processing procedures. Workshops are announced in bulletins, newsletters and on the OHCA Web site at http://www.okhca.org. Group training can also be arranged at the request of individual provider groups or associations.
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The following information should be provided to assist your field consultant in planning the visit or workshop:
 Provider type and specialty attending the seminar.
 Number of attendees.
 Time and location of the event.
 Issues to be addressed.
 Point of contact, in case additional information is needed prior to the event. Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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HHPP FFiieelldd CCoonnssuullttaanntt RReepprreesseennttaattiivveess CCoonnttaacctt IInnffoorrmmaattiioonn
Region
Phone Number
Counties within the Region
I
405-416-6715
Alfalfa, Beaver, Cimarron, Dewey, Ellis, Garfield, Grant, Harper, Kay, Kingfisher, Lincoln, Logan, Major, Noble, Payne, Pottawatomie, Texas, Woods, Woodward
II
405-416-6739
Adair, Cherokee, Craig, Creek, Delaware, Mayes, Muskogee, Nowata, Osage, Ottawa, Pawnee, Rogers, Sequoyah, Wagoner, Washington
III
405-416-6720
Beckham, Blaine, Caddo, Canadian, Cleveland, Comanche, Cotton, Custer, Garvin, Grady, Greer, Harmon, Jackson, Jefferson, Kiowa, McClain, Roger Mills, Stephens, Tillman, Washita
IV
405-416-6763
Atoka, Bryan, Carter, Choctaw, Coal, Haskell, Hughes, Johnston, Latimer, LeFlore, Love, McCurtain, McIntosh, Marshall, Murray, Okfuskee, Okmulgee, Pittsburg, Pontotoc, Pushmataha, Seminole
V
405-416-6740
Oklahoma County
VI
405-416-6716
Tulsa County
Out-of-state consultant: 405-416-6730
Field staff supervisor: 405-416-6768
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RReeggiioonnaall MMaapp
MMEEDDIICCAAIIDD OONN TTHHEE WWEEBB//SSEECCUURREE SSIITTEE
Medicaid on the Web is the OHCA‟s secure Web site, offering providers a number of services from submitting claims on the Web to fast verification of claim status. New providers are assigned a PIN to access the Web site.
To access the page, go to www.okhca.org, click on the Provider tab and choose Secure Site from the drop-down menu. For more information on logging in for the first time and entering the secure site, look under the Help tab on the Web site. Medicaid on the Web is available from 5 to 1 a.m.
AAvvaaiillaabbllee SSeerrvviicceess
The following services are available to Medicaid on the Web users: Global messaging (can be specific to one or all providers). Claims submission. Claims inquiry. Prior authorization submission. Provider PA notice. Prior authorization inquiry. Procedure pricing. Financial warrant amount. Eligibility verification. Managed Care rosters. Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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SECTION D: WRITTEN INQUIRIES
When inquiring in writing about the status of a SoonerCare claim, use the SoonerCare Claim Inquiry/Response form HCA-17. A sample of this form is found in the Forms chapter of this manual. Follow the instructions on the form. Attach a copy of the original claim and any supporting documentation, such as a copy of the remittance/denial, PCP/CM referral, Medicare EOMB, consent forms or medical records required for review.
Mail Inquiry/Response forms, policy questions and any other written correspondence regarding hard-to-resolve SoonerCare claims to:
The OHCA
Attention: Provider Services
P.O. Box 18506
Oklahoma City, OK
73154-0506
MMAAIILLIINNGG CCLLAAIIMMSS
Original, corrected and re-filed claims are submitted to the fiscal agent at the appropriate address listed in the General Information chapter of this manual. Claims mailed to addresses other than the assigned P.O. Box might result in payment delays. For a list of mailing addresses, see the General Information chapter of this manual.
Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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Provider Billing And Procedure Provider Billing And Procedure Manual Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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INTRODUCTION
SoonerCare Choice is Oklahoma‟s Medicaid Managed Care program. The program began in 1996 in 61 rural counties in Oklahoma. It was expanded statewide in April 2004 to include urban counties that had been previously covered under the SoonerCare program. The Choice program provides primary and preventive health care services. Health care is provided and managed by a Primary Care Provider/Case Manager (PCP/CM) that contracts to be a medical home for members on their panel. The level of medical home determines the care coordination payment the PCP receives. All other services are pay based on the OHCA current FFS payment methodology. PCP may also qualify for SoonerExcel incentive payments based on individual performance.. Physicians, nurse practitioners and physician assistants in primary care specialties can contract as PCP/CMs.
Quality Assurance
The OHCA is committed to ensuring that high quality health care is always available to its members. SoonerCare Choice providers agree to cooperate with external review organizations, internal reviews and other quality assurance efforts.
QQuuaalliittyy AAssssuurraannccee ((QQAA)) TToooollss
Quality assurance measures may include:
CAHPS Report Card
Annual telephone and mail surveys of SoonerCare Choice members are conducted by an external review organization, which measures health care satisfaction, including care provided by their PCP/CM.
After-Hours Surveys
Telephone surveys are conducted by the OHCA or one of its agents to ensure that PCP/CMs provide information concerning after-hours access to medical information or a medical professional.
Member Reports
Member calls to the SoonerCare Helpline for issues regarding quality of care or access to care needs are documented and forwarded to the OHCA for research and/or resolution.
On-Site Audits
On-site audits are conducted by OHCA Quality Assurance/Quality Improvement staff.
Encounter Data Reviews
Data reflecting medical care use rates, preventive care services and referral patterns are reviewed and analyzed. This information is Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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used in determining use patterns, referral patterns, rate setting and other reporting purposes.
Emergency Room Utilization Profiling
OHCA Quality Assurance/Quality Improvement staff perform quarterly analysis of PCP/CM office encounter claims submission versus emergency room claim submission. The results of these reports are forwarded to the PCP/CMs as well as SoonerCare Provider Services. The goal of this project is to reduce inappropriate use of emergency rooms.
SECTION A: COVERED MEMBERS
The Oklahoma Department of Human Services (OKDHS) determines the eligibility for all SoonerCare members. Members must meet financial, residency, disability status and other requirements before they can become eligible for SoonerCare.
SoonerCare Choice covers members who qualify for medical services through the Temporary Aid to Needy Families (TANF) program or those who qualify due to age or disability. Members may also include women who have been diagnosed with breast or cervical cancer under Oklahoma Cares, or children with disabilities who qualify under the Tax Equity and Fiscal Responsibility Act (TEFRA).
NNAATTIIVVEE AAMMEERRIICCAANNSS
Native Americans who are eligible for SoonerCare Choice must enroll with a Primary Care/Case Manager. They may choose a traditional SoonerCare Choice provider or enroll with an Indian Health Service, Tribal, or Urban Indian (I/T/U) clinic provider that participates in the program. All Native American members have the option to self-refer to any I/T/U facility for services that can be provided at these facilities.
SSOOOONNEERRCCAARREE CCHHOOIICCEE EEXXEEMMPPTT
Most members who are eligible for SoonerCare benefits will be enrolled in the SoonerCare Choice program. Individuals exempt from this mandate are eligible for Medicare and SoonerCare Traditional; enrolled in a waiver program, (examples being. Advantage or Home/Community waiver); residing in a long-term care center or institution; enrolled in a private Health Maintenance Organization (HMO); or a subsidized adoption. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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SECTION B: ACCESS TO CARE
SoonerCare Choice PCP/CMs are required to maintain access to primary and preventive care services in accordance to its contract. The following standards apply:
1. PCP/CMs must maintain 24 hour, seven day per week telephone coverage, which will either page an on-call medical professional or give alternate information to members concerning who they can contact to obtain medical advice. PCP/CMs are allowed to use the SoonerCare Patient Advice Line (PAL) for this purpose during the PAL‟s operating hours. These hours are 5:00 p.m. to 8:00 a.m. Monday through Friday. The PAL is available 24 hours per day on weekends and state of Oklahoma legal holidays. Please note, the PAL is not intended to replace a PCP/CMs obligation to assess and triage patients during normal business hours.
2. PCP/CMs must offer hours of operation that are no fewer than the hours of operation offered to commercial patients or SoonerCare Traditional members.
3. PCP/CMs must provide medical evaluation and treatment within 24 hours for urgent medical conditions. Generally, urgent care is for sudden illnesses or injuries where there is no immediate danger of death or permanent disability.
4. PCP/CMs must provide routine or non-urgent medical care within three weeks. Routine physicals or chronic conditions that require less frequent care may be excluded from this three-week period.
5. PCP/CMs that provide services to members 18 years old or younger are required to participate in the Vaccines for Children program through the Oklahoma State Department of Health (OSDH) and document immunization data in the Oklahoma State Immunization Information System (OSIIS) database.
o PCP/CMs can charge a co-payment to choice members.
Emergency Care
PCP/CMs are not required to provide emergency care either in its office or in an emergency room. PCP/CMs that do provide emergency care in the emergency room will be reimbursed based on current OHCA policy.
PCP/CMs should not refer members to an emergency room for non-emergeny services. Providers should interact with its assigned members to discourage inappropriate emergency room use. PCP/CMs should manage follow-up care from the emergency room, as needed. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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SECTION C: MEMBER ENROLLMENT/DISENROLLMENT
SSOOOONNEERRCCAARREE CCHHOOIICCEE EENNRROOLLLLMMEENNTT EEXXCCEEPPTTIIOONNSS
Exceptions to enrollment in SoonerCare Choice are individuals who are enrolled in an HMO; in a subsidized adoption; in a nursing home or special care center; in a home and community-based waiver; or eligible for Medicare and SoonerCare Traditional coverage.
SoonerCare member benefits start when DHS determines eligibility for SoonerCare Traditional and certifies the case. The effective date of SoonerCare Choice members‟ benefits depend on the certification date. Always check the Eligibility Verification System (EVS) either by calling the toll-free EVS line, through the swipe machine or on the Medicaid on the Web Secure Site.
NOTE: Medical care during the time a member is eligible for SoonerCare Traditional, but not yet effective in SoonerCare Choice, will be covered under the SoonerCare Traditional fee-for-service program.
Continuing eligibility for SoonerCare benefits must be recertified periodically. The recertification intervals vary according to the type of assistance members receive. SoonerCare members are notified in writing by DHS prior to the expiration of benefits.
Breaks in eligibility may mean a disruption in continuity of care. If the PCP/CM‟s capacity is limited in comparison to demand, the member may not be able to regain his or her place on that PCP/CM‟s panel.
Members may reenroll with a PCP/CM by calling the SoonerCare Helpline if they have a break in eligibility and are being recertified. Members who lose and regain eligibility within 365 days are assigned to their most recent PCP/CM, if the PCP/CM has available capacity and is within the PCP/CM‟s scope of practice.
Choosing a PCP/CM
The OHCA offers all members the opportunity to choose a PCP/CM from the provider directory. If a member does not choose a PCP/CM, the OHCA will contact the member to assist them in choosing a medical home. If a member seeks care prior to choosing a medical home the provider seeing the member will be the medical home.
Families with more than one eligible member are allowed to choose a different PCP/CM for each eligible member. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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Enrollment with a PCP/CM takes effect at the beginning of each month. Prior to the first day of each month, the OHCA provides the PCP/CM with a SoonerCare Choice eligibility listing of new enrollees and continuing members.
Capacity (Number of Members requested per PCP/CM)
The PCP/CM specifies the maximum number of members he or she is willing to accept. The maximum number is 2,500 members for each physician PCP/CM. The maximum capacity for physician assistants and nurse practitioners serving as PCP/CMs is 1,250. The PCP/CM must agree to a minimum panel of 50 members. The OHCA cannot guarantee the number of members a PCP/CM receives.
A PCP/CM may request a change in its capacity by submitting a written request to the Provider Enrollement division of the OHCA. If approved, the OHCA will implement the change on the first day of the month with sufficient notice.
If a PCP/CM requests a lower capacity - within program standards and it is approved by the OHCA - the reduction in members will come through members changing PCP/CMs or losing eligibility. Members will not be disenrolled to achieve a lower capacity.
Changing PCP/CMs
The OHCA or the SoonerCare Helpline may change a member from one PCP/CM to another PCP/CM for the following reasons: Member can request change without cause. When a PCP/CM terminates his or her participation in the SoonerCare Choice program.
Disenrollment At The Request of the PCP/CM
The OHCA may also change a member from the assigned PCP/CM to another PCP/CM for good cause and upon written request of the assigned PCP/CM. If the request is a good cause change, the OHCA will act upon the request within 30 days of receipt from the OHCA SoonerCare Choice division.
Good cause is defined as: Non-compliance with PCP/CM‟s direction. Abuse of PCP/CM and/or staff (includes disruptive behavior). Deterioration of PCP/CM- member relationship. Three no-show appointments.
The dismissal request and supporting documentation should be forwarded for processing to SoonerCare at 405-530-3228. Members may not be notified by the PCP/CM until approval for disenrollment is granted by the OHCA. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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Either party has the right to appeal the decision to the administrative law judge, pursuant to OAC 317:2-1-2 (the Authority‟s Grievance Procedure)
SECTION D: REFERRALS
SoonerCare Choice referrals are made on the basis of medical necessity as determined by the PCP; are required prior to receiving the referred service, except for retrospective referrals as deemed appropriate by the PCP/CM; and must have the correct provider referral number to ensure payment to the “referred to” provider (provider/referral numbers are site specific).
Referrals must be signed by the PCP/CM or a designee within the PCP/CM‟s office who is authorized to sign for the provider.
Some services may also require prior authorization. It is up to the “referred to” provider, or provider ordering services, to obtain prior authorization as needed. Prior authorization for services is obtained through the Medical Authorization Unit at OHCA.
SoonerCare Choice referrals must be made if the member requests a second opinion when surgery is recommended. Following the second opinion, any treatment received by the member is to be rendered by the PCP or through a referral made by the PCP/CM.
SoonerCare Choice referrals may be made to another PCP/CM for services equal to those of a specialist. Examples of this are, a family practitioner could refer to another family practitioner who performs a surgical procedure, or a general practitioner could refer to an internist who manages complicated diabetic patients.
SoonerCare Choice referrals may be made to a provider for ongoing treatment for time specified by the PCP/CM, but limited to 12 months. For the duration of the referral, the referred-to provider will not be required to receive further referrals to provide treatment for the specific illness indicated on the referral.
SoonerCare Choice referrals are not required for child physical/sexual abuse exams; services provided by a PCP/CM for members enrolled or assigned to the PCP/CM; emergency room care; obstetrical care; vision screenings for members younger than 21 years; Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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basic dental for members younger than 21 years (benefit is limited to emergency extractions for members older than 21 years); behavioral/mental health; family planning; inpatient professional services; routine laboratory and x-ray; or services provided to Native Americans in a tribal, IHS or Urban Indian Clinic facility.
Payment of Referred Services
Payment for referred services is subject to coverage limitations under the current SoonerCare reimbursement policies. Payment for referred services are limited to four specialty visits per month for adults older than 21 years. Visits to their PCP are excluded from this limitation. To ensure payment, PCP/CMs must refer only to SoonerCare providers that have an active SoonerCare Traditional contract.
Documenting the Medical File
Documentation in the medical record should include a copy of each referral to another health care provider and any additional referrals made by the referred-to provider when this information is known. An example might be ancillary services.
Documentation in the medical record should include a medical report from the referred-to provider. The referred to provider should report its findings to the referring PCP/CM within two weeks of the member‟s appointment. In the event a medical report is not received within a reasonable time, the PCP/CM should contact the referred-to health care provider to obtain this information.
Unauthorized Use of Provider Number
Unauthorized use of a SoonerCare Choice NPI number may result in official action to recover unauthorized reimbursements from the billing provider.
Referral Form and Instructions
In the SoonerCare Choice program, the PCP/CM is responsible for providing primary care and making specialty referrals. The PCP/CM completes the referral form, including the referral number. The PCP/CM‟s SoonerCare Choice NPI number serves as their referral number. The provider/referral number is site specific and must be for the site where the member is enrolled or assigned. The referral includes ancillary services rendered, or required, by the “referred to” specialist. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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With the PCP/CM‟s approval, a specialist may relay a copy of the original referral to other specialists with instructions considered necessary for proper member treatment. Payment is subject to the current SoonerCare reimbursement policies.
The provider mails the original of the completed form to the specialist, or “referred to” provider. A copy of the form is retained in the patient‟s medical record.
When a claim is submitted by a “referred to” provider, the referral number must be entered in box 17a of the 1500 claim form, or box 30 of the UB-04 hospital claim form. A copy of the referral should not be attached to the claim. If the referral number is not on the claim form, payment will be denied unless for self-referred services.
Referral forms can be accessed and printed from the Forms page on the OHCA Web site at www.okhca.org.
SECTION E: EPSDT
Early and Periodic Screening Diagnosis and Treatment (EPSDT) is a federally mandated program and one of the highest priorities of the SoonerCare Choice program. EPSDT is designed to provide a comprehensive program of preventive screening examinations, dental, vision, hearing and immunization services to SoonerCare Choice members age 20 or younger.
Schedule of EPSDT Services
As a minimum, the following schedule for EPSDT screening is required: Six visits during the first year of life. Two visits in the second year of life. One visit yearly for ages two through five. One visit every other year for ages six through 20. Metabolic lead screen at ages one and two; or six years old if not done by age 2. This is mandatory.
Additional Requirements
The OHCA requires contractors to: Conduct and document follow-up appointments with all members younger than 21 years old who miss appointments. Administer outreach, including telephone calls or printed notification mailed to a member when a health care screen is indicated or missed. This ensures that all members who are age 20 or younger are current. Educate families of members age 20 or younger about the importance of early periodic screening, diagnosis and treatment. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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EPSDT Bonus Payment
The OHCA offers bonuses paid to PCP/CMs that demonstrate a specified screening rate.
To qualify for the EPSDT bonus, verifiable encounter claim data must be submitted in a timely manner as set forth in the SoonerCare Choice contract (Section 6.2 for year 2007) and for any following contract addendums.
The OHCA may conduct onsite chart audits.
See the Reimbursement section below for further bonus payment details.
SECTION F: REPORTING REQUIREMENTS
Data, information and reports collected or prepared by the PCP/CMs in the course of performing its duties and obligations as a PCP/CM are owned by the state of Oklahoma. The OHCA and other appropriate entities reserve the right to examine this information upon request. This information includes medical and financial records, accounting practices, and other items relevant to the provider‟s contract.
The PCP/CM is required to report to the OHCA in writing and within a timely manner any changes to its SoonerCare Choice contract. The report must include demographic, financial and group composition information as reported in their contract.
Claims submitted by the PCP/CM should be submitted in the same manner and on the same claim forms used to submit claims for SoonerCare Traditional members. Encounter Claims must be submitted within 60 days from the date of services. Denied claims must be corrected and resubmitted within 60 days of adjudication.
SECTION G: REIMBURSEMENT
CCHHAANNGGEE TTOO CCAARREE CCOOOORRDDIINNAATTIIOONN
SoonerCare Choice PCP/CMs are paid a care coordination payment for each member enrolled with them on a monthly basis.
Care Coordination payments vary according to the type of members the PCP services and their level of medical home status.
Care Coordination payments are made by the 10th working day of each month for all eligible members enrolled with the PCP/CM on the first of each month. A single monthly payment is generated and accompanies the Care Coordination Listing or is deposited directly. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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CCLLAAIIMMSS
PCP/CMs are required to file a claim with the OHCA each time a service is provided to a member. Claims filed will be paid subject to the current SoonerCare Traditional fee schedule and reimbursement policies.
Claims are to be submitted on a 1500 claim form within 60 days of the date the service was provided.
TTAANNFF SSTTOOPP LLOOSSSS
To limit risk to PCP/CMs, a threshold of $1,800 per year in capitated services ($450 per quarter) is established by the stop-loss for members eligible through TANF. This is based on the SoonerCare Traditional fee schedule allowables; not gross charges.
IIMMMMUUNNIIZZAATTIIOONN IINNCCEENNTTIIVVEE PPAAYYMMEENNTT
Immunization Incentive Payments are available when the PCP/CM provides written notice that it has administered the 4th dose of DPT/DTAP to a member before the member‟s second birthday.
SECTION H: PROVIDER RESOURCES
SoonerCare Choice PPRROOVVIIDDEERR RREEPPRREESSEENNTTAATTIIVVEESS
1. SoonerCare PCP/CMs and all other SoonerCare providers have provider representatives to answer questions or policy issues, research complex claim issues and provide onsite training and support. These provider representatives can be reached by calling toll free at 877-823-4529, option 2. Provider representatives will be available to assist you with questions, claim resolution or directing you to your on-site provider representative.
EDS Field Consultants
EDS field consultants make onsite visits to assist providers with billing questions and train providers to summit online claims through the OHCA Web site. The field consultants conduct bi-monthly training sessions along with the spring and fall workshops. Providers can locate their EDS field consultant by visiting the OHCA Web site at www.okhca.org. Once there
1. click on the Provider link in the center of the page;
2. click on the Training link under the Providers header on the left side of the next page; and
3. click on the EDS Field Consultants link on the right of the next page where you will find your field consultant.
Patient Advice Line
The Patient Advice Line is a service available only to SoonerCare Choice members. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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AAuuddiioo TTaappee LLiibbrraarryy
The Member Handbook lists a few of the more than 1,100 recorded topics accessible on the Patient Advice Line.
SSoooonneerrCCaarree CChhooiiccee PPaattiieenntt AAddvviiccee LLiinnee is accessible Monday through Friday, 5 p.m. to 8 a.m., 24 hours on weekends and state of Oklahoma legal holidays; offers triage services to members based on nationally recognized triage protocols; and is staffed by registered nurses.
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Your after hours recording may instruct your SoonerCare Choice members to call the Patient Advice Line; however, the Advice Line serves as a supportive program and is not a replacement for after-hours provider coverage.
The Patient Advice Line offers assistance in determining if the caller has an emergency or urgent care need and educates the caller on home care.
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If the Patient Advice Line directs the member to seek emergency room care, your office and the SoonerCare Division of the OHCA will receive fax notifications the next business day.
SoonerCare Choice Patient Advice Line
Toll-free at 800-530-3002
Hearing impaired, dial SBC Relay Oklahoma at 800-722-0353 (TDD/TTY)
Translation Services
The SoonerCare Helpline offers translation services 24 hours a day, seven days a week. If you cannot communicate with the member because of language, call the SoonerCare Helpline at 1-866-872-0807 and enter state code 53510.
The Patient Advice Line (PAL) is available for translation services from 5 p.m. to 8 a.m. weekdays and 24 hours per day on weekends and state holidays. Please call PAL at 800-530-3002 for assistance during these times. The PAL contract with AT&T‟s translator service accommodates more than 140 languages and dialects. Physicians with a SoonerCare Choice member who does not speak English can use this service during the member‟s office visit. They can also connect with this service any time a non-English speaking member calls.
CCAARREE MMAANNAAGGEEMMEENNTT The Care Management Department is comprised of registered nurses and licensed practical nurses. These medical professionals Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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assist in facilitating medical services for SoonerCare members with complex medical conditions.
CCaarree MMaannaaggeemmeenntt SSeerrvviicceess help members access care and services; assist providers with coordination of discharge planning; resolve issues and concerns with providers as related to medical care; help get approvals for medicines and medical services; provide patient education to identified groups; assist with coordinating community support and social service systems; and offer out-of-state referrals if no comparable in-state services are offered or in cases of urgent care needs.
CCoommpplleexx mmeeddiiccaall ccoonnddiittiioonnss iinncclluuddee high risk OB cases; transplant cases; catastrophic illness or injury; women enrolled in the Breast and Cervical Cancer (BCC) program; and children receiving in-home Private Duty Nursing services (includes periodic home visits to evaluate & certify medically necessary services).
QQuuaalliittyy AAssssuurraannccee oovveerrsseeeess iissssuueess wwiitthh Care Management Referral forms; high service utilization; medical regimen noncompliance; inappropriate ER visits; multiple providers/pharmacies; scheduled medication requests; refusing alternate treatments/prescriptions; refusing pain management referrals; and drug seeking behaviors.
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INTRODUCTION
The OHCA contracts with the Oklahoma Department of Human Services (OKDHS) to determine Medicaid SoonerCare eligibility using federal and state eligibility criteria. Most Medicaid SoonerCare criteria related to income levels are determined by the federal poverty guidelines established by the U.S. Department of Heath and Human Services. Visit the Oklahoma Department of Human Service Web site at http://www.okdhs.org/programsandservices/health/ to obtain additional information on member enrollment in medical services.
SECTION A: MEMBER ID CARD
Medicaid SoonerCare members receive a permanent plastic identification card. The Medicaid Medical ID card is a white card with brown and green graphics. The card can be used for accessing the EVS system or a commercial swipe machine system to verify a member‟s eligibility before providing a Medicaid SoonerCare service. Shown below is an example of the medical ID card.
Members are encouraged to keep their card with them at all times; however, this card is not required to be provided by the member to receive services. Eligibility can be verified by using the member‟s ID number from their card, member‟s Social Security number with member‟s date of birth, member‟s first and last name along with date of birth or the member‟s DHS case number; leaving off the 2-digit person code. It‟s the provider‟s responsibility to verify the member‟s eligibility on a per visit basis to ensure the member‟s continued eligibility for Medicaid SoonerCare coverage. Failure to verify eligibility prior to rendering services could result in a delay or denial of payment.
SECTION B: OPTIONS TO VERIFY MEMBER ELIGIBILITY
As an Oklahoma Medicaid SoonerCare provider, it is imperative that the member‟s eligibility is verified before providing any services. Providers can check a member‟s eligibility using one of Chapter 4: Member Eligibility Verifications The OHCA Provider Billing And Procedure Manual
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four sources: Eligibility Verification System (EVS), the secure Web site, swipe machines or Electronic Data Interchange (EDI). The purpose of the ID card is to give sufficient information to verify eligibility of the member. The card by itself is not a guarantee of eligibility. Providers need a Personal Identification Number (PIN) to access the Oklahoma Medicaid secure Web site and the EVS. If a provider forgets their PIN, they can obtain it by calling the Security Help Desk toll free at 800-522-0114 or within the Oklahoma City metro area at 405-522-6205 and selecting options 2 then 1.
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The EVS provides a national toll-free telephone number to help providers obtain member eligibility, third party liability (TPL), warrant, prior authorization and claim inquiry information. Providers can also request prior authorization and eligibility fax backs. There are two ways to use the EVS system. A caller may use the touch-tone system or the automated voice response (AVR)/speech recognition system. A PIN is required to access member eligibility information. The four-digit PIN expires every six months. Providers may reset their PIN by staying on the phone and following the prompts.
TToouucchh--TToonnee SSyysstteemm
The touch-tone system allows a caller to go through the call by using the telephone‟s number pad. The caller‟s telephone must have touch-tone capability, as rotary style phones will not work on the touch-tone system.
AAllpphhaa CCoonnvveerrssiioonn
Entering the provider‟s SoonerCare ID number can access eligibility information. This will be a nine-digit number and the one alpha character location code that was assigned by the OHCA. A location conversion code has been established for the alphabet to be used in conjunction with the EVS. The codes are patterned to coincide with the location of numbers and letters on a telephone keypad. For example, the letter A converts to *21. The number 21 represents the second button and the first letter on the second button of the telephone keypad. The letter R converts to *72, representing the seventh button, third letter. See the alpha conversion chart below. Chapter 4: Member Eligibility Verifications The OHCA Provider Billing And Procedure Manual
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Alpha Conversion Chart for EVS
AAVVRR//SSppeeeecchh RReeccooggnniittiioonn
Providers without a touch-tone phone can access information using the AVR. The AVR system allows a caller to use a speech application. By speaking into the phone, a caller is able to use the system to get all the information they need. The system is available seven days a week from 5 a.m. to 1 a.m.
Nationwide Toll Free: 800-767-3949
Oklahoma City Metro Area: 405-840-0650
Secure Site Eligibility Verification
Providers have the ability to verify member eligibility through the Secure Web site. They do this by logging into the secure site and clicking on the Eligibility tab. The member may use his or her ID number, Social Security number with date of birth, the member‟s first and last name along with date of birth or the DHS case number to check eligibility. This must be combined with the “from” and “to” dates of service. Arrow buttons next to the date-of-service fields activate a calendar pop-up feature to aid in selecting dates. The resulting data appear below the search criteria. When searching eligibility on the secure Web site, the Web site will display a verification number and a status of A or N. The verification number and the status do not reflect the member‟s eligibility. The member‟s eligibility information is listed under the section titled “Eligibility”. Checking eligibility on the secure Web site will also give Third Party Liability (TPL) and Medicare coverage information.
Swipe Card
This device, similar to a credit card machine, hooks into a phone jack. The provider swipes the Medicaid SoonerCare ID card through the reader, which reads the magnetic strip. The eligibility information is displayed on the screen or printed on a paper slip. Providers interested in the swipe card option can contact a third party vendor for details.
Electronic Data Interchange (EDI)
EDI is a way for providers to check eligibility on a larger scale than the previous options. Providers purchase third party, HIPAA compliant software used to send a 270 transaction with their search
A=*21
F=*33
K=*52
P=*71
U=*82
Z=*12
B=*22
G=*41
L=*53
Q=*11
V=*83
C=*23
H=*42
M=*61
R=*72
W=*91
D=*31
I=*43
N=*62
S=*73
X=*93
E=*32
J=*51
O=*63
T=*81
Y=*93
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criteria and receive a 271 response, which provides eligibility information. A 271 will give providers information on the different programs the member has as well as any TPL or Medicare information.
Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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INTRODUCTION
The OHCA secure site is one of the most exciting features of the Oklahoma Medicaid Management Information System (MMIS). The efficiency and convenience of the Internet remote access server (RAS) gives all Oklahoma SoonerCare providers fast access to member and provider specific information. Any SoonerCare provider can access the Web/RAS with its Provider ID and an OHCA-generated personal identification number (PIN). Once the provider has established a free account, they can create new clerks and grant each clerk role-specific access. The Web/RAS is always available.
IIMMPPOORRTTAANNTT WWEEBB SSIITTEE NNOOTTEESS:: User names and passwords are case sensitive. All dates should be entered in MMDDYY format. Dollars and cents should be separated by a decimal. Line totals will not be calculated automatically; the user must multiply the units by the unit rate to ensure the correct total billed amount. Do not populate the TPL amount unless another payer has paid a specific amount toward the claim. Decimals should not be used when entering diagnosis codes.
SECTION A: ACCESSING THE SECURE WEB SITE
The secure Web site can be reached through the public Internet. All that is required are Microsoft Internet Explorer browser version 6.0 or higher 128 bit encryption; and customized security settings to access information across domains.
Windows 98 users will need Microsoft updates. For more information on required updates, please contact EDS Internet Help Desk.
GGEETTTTIINNGG TTOO TTHHEE SSEECCUURREE WWEEBB SSIITTEE
1. Go to www.okhca.org.
2. Under the Provider header in the center of the screen (see Screen Sample 5.1), click on the “Secure Site” link to get to the OHCA secure site. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.1
NOTE: On the OHCA Web site, providers have complete access to all the latest Oklahoma Medicaid related information and updates.
LLOOGG OONN PPAAGGEE
The Log On page serves as the access point for all Internet users. Users will begin account initialization and log on from this page, once accounts are established.
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Screen Sample 5.2
AACCCCOOUUNNTT IINNIITTIIAALLIIZZAATTIIOONN
A user will go through an initialization process the first time they log on to the secure site (see Screen Sample 5.2). This will differ depending on the security level of the user.
LLOOGGGGIINNGG OONN
1. Enter the secret ID specific to your role:
Providers - Under „First Time Here,‟ enter the Provider ID number in the Log On ID field. This does not include the service location alpha character. (i.e. 123456789).
Billing Agents – Under „First Time Here‟ enter the submitter ID given to you by EDI in the Log On ID field.
Clerks – Under „Already a Member‟ enter the name generated by your provider or billing agent. Enter the password in the Password field and skip Step 2.
2. Enter the 9-character PIN in the PIN field.
3. Click the Log On button at the bottom of the page.
4. After clicking logon a popup window will appear called the OHCA usage security agreement statement. There will be I Agree and I Disagree options at the bottom. Clicking I Agree will take you to the Account Maintenance Screen. Clicking I Disagree will bring you back to the logon page.
NOTE: This statement will not appear if a popup blocker is on. It will go to the account maintenance screen, which will ask you to save. All popup blockers must be turned off in order to see the popup screen with the Save button. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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4. Enter a user name in the User Name field. The user name must start with a letter of the alphabet and be six to 12 characters.
5. Enter a password in the New Password field. The password must begin with a letter of the alphabet, be six to eight characters and contain no fewer than two numeric characters.
6. Confirm the password by retyping it into the Confirm Password field.
7. Enter a contact name in the Contact Name field. Providers need to enter the clerk‟s full name. Clerks are not authorized to do this.
8. Enter an e-mail address in the E-mail field.
9. Enter phone number in the Phone Number field.
10. Enter two self-authentication questions and answers. Clerks only.
11. Click on the Submit button.
If all data was entered correctly, a box will pop up telling you that your data have been successfully saved.
12. Click the OK button.
13. Click on the Save button.
14. Click the Log Out button.
After setting up your user name and password, future login attempts are done at „Already a member?‟ by entering the user name in the User Name field and entering the password in the Password field.
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Providers will receive a letter by mail containing the provider‟s access PIN. This PIN, used in conjunction with the Provider ID, will grant the provider initial access to the secure Web site. Only providers with an active SoonerCare contract will receive a PIN letter. Separate PIN letters will be mailed to each location. It is recommended that providers initialize their account and immediately create Level 2 users (clerks) that will be used to operate the Internet application on a daily basis. Operating daily under the Level 1 (Provider) master user poses certain security risks and should only be used when managing the account.
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Billing agents are given log-on credentials directly from the OHCA. When the users initialize their accounts, they will be forced to establish a password and contact information. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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LLeevveell 22 ((CClleerrkkss))
The provider or billing agent that created the clerk will give clerks log-on credentials. Users will be required to establish a password, contact information, and self-authentication questions and answers upon initializing their accounts.
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Drug manufacturers must request online access. A PIN letter will be mailed to the requesting company once the user requests access and the request is approved. Users will establish a password, contact information, and self-authentication questions and answers upon initializing their accounts.
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Other users include: The Oklahoma Department of Human Services (OKDHS) and any other agency that intends to access the secure Web site via the public Internet. Internet users of this type will be created by the OHCA administration, and credentials will be given to them. Users will establish a password, contact information and self-authentication questions and answers when initializing their accounts.
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Users who forget their passwords may still gain access to the secure Web site through the self-authentication process. The self-authentication process requires the user to change his or her password.
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Users who forget their password must provide his or her PIN and Provider ID. Valid data will take users to the account maintenance page where they will create a new password. They will go to the secure Web site after the new password is set.
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Billing agents or clerks that forget their passwords can click on the Tab, “Forgot Password?” and answer the two secret questions they set up the first time they logged on. They are then taken to their account maintenance screen to change their password.
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SECTION B: WEB FEATURES
The OHCA secure site has many features to help providers with everything related to Medicaid billing. This section will cover several OHCA secure site features.
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This is the first page the user will see after logging on. It will have global messages from the OHCA that can be directed to an individual provider, a specific provider type, or to the entire provider community.
After reading each message, click on the Read box. This will move the message to the Mailbox for future reference until it expires.
After reading all messages, click on the Next button.
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The Main page is the user‟s home page. The Main page shows the User ID and the taxonomy number, provides information about the direction of remittance advices and contains shortcut links to all areas of the Web site.
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This Main page is only available to drug manufacturer users. It contains a brief description of the features available to drug manufacturers, a phone number to call for questions and a link to the download page.
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The Switch Provider page is only available to clerks and billing agents. This feature allows the user to select the provider he or she wishes to access. The provider must grant access to the billing agent or other user through the Account Maintenance page before this functionality is available. To switch to a different provider, click the hyperlink of the desired provider ID found on the Main page. The “Next” button will take the user back to the Main page.
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The Claims Page facilitates the communication of claim data between the OHCA and the provider community.
Providers without access to HIPAA compliant Practice Management software, a clearinghouse or a virtual access network (VAN) still have the ability to submit claims electronically. Direct data entry (DDE) enables the provider to submit individual claim information electronically to OHCA/EDS without the constraints of having to submit the data in HIPAA compliant format. DDE claim pages are available on the OHCA secure Web site for all claim types (i.e. professional, institutional, dental and pharmacy). Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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These pages contain separate box/fields where claim data must be populated. As with paper claim forms, box/field population requirements depend on the billing situation. However, if a provider attempts to submit a claim via the DDE page and has not populated all required fields, the system will prompt a pop-up box stating which required fields are unpopulated.
Direct Data Entry processes can only be performed one claim at a time.
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Users may inquire about claims already submitted to the OHCA/EDS using client ID, patient account number, internal control number (ICN), status, dates of service and warrant dates. A results box from the search will appear below the search criteria in the form of a summary list. Twenty results will appear at a time with navigation links below the box to view the next or previous list of results from the query. Each summary result item is hyperlinked to the claim detail page in the ICN and hyperlinked to the Client Eligibility page in the Client ID.
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1. Click on the Claim Inquiry link, or move mouse pointer over the Claims tab, highlight Claim Inquiry and click on it.
2. If known, the client ID number can be entered in the Client ID field.
3. The Claim Status field can be set to, „Any Status,‟ „Denied,‟ „Paid,‟ „Suspended,‟ or „Resubmit‟.
4. If the patient account number is known, it can be entered into the Patient Acct. # field.
5. Choose a date type by selecting either the „Date of Service‟ or „Warrant Date‟ Date Type radio buttons.
6. If known, the ICN can be entered in the ICN field.
7. The from date of service can be entered into the From Date field, and the thru date of service can be entered into the Thru Date field.
8. Click on the Search button.
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CCllaaiimm SSuubbmmiissssiioonn
Providers need to confirm that they are logged in under the correct provider number location before starting claim submission.
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1. Pull up „Denied‟ claims (from the Claim Status field), along with any other search criteria.
2. Click on the ICN link of the claim that needs correction.
3. Change the information in the field containing the incorrect data and click on the Re-Submit button.
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1. Pull up „Paid‟ claims (from the Claim Status field), and any other search criteria.
2. Click on the ICN link of the claim that needs to be voided.
3. Click on the Void button. This will create an account receivable for the amount previously paid, which will be deducted from a future warrant.
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1. Pull up „Paid‟ claims (from the Claim Status field), along with any other search criteria.
2. Click on the ICN link of the claim that needs to be copied.
3. Click on the Copy Claim button. Make any changes to Client ID number, procedure codes, date of service or any other fields you need changed to make a new claim.
4. Click the Resubmit button.Institutional Claim Submission From this page, users may submit, resubmit, adjust and void institutional claims. Claims are sent as HIPAA compliant .xml format. The page includes field edits for data format and required fields. Claim adjudication response is immediate and EOBs display in real time below the claim form in the claim status box.
Professional Claim Submission
From this page users may submit, resubmit, adjust, and void professional claims. Claims are sent as HIPAA compliant .xml format. The page includes field edits for data format and required fields. Claim adjudication response is immediate and EOBs display real time below the claim form in the claim status box.
Dental Claim Submission
From this page, users may submit, resubmit, adjust and void dental claims. Claims are sent as HIPAA compliant .xml format. The page includes field edits for data format and required fields. Claim adjudication response is immediate and EOBs display in real time below the claim form in the claim status box. Pharmacy Claim Submission From this page, users may submit, resubmit, adjust and void pharmacy claims. Claims are sent as HIPAA compliant .xml format. The page includes field edits for data format and required fields. Claim adjudication response is immediate and EOBs display in real time below the claim form in the claim status box. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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The purpose of the Eligibility page is to verify eligibility of SoonerCare members. To run a query, a valid client ID, Social Security number and date of birth, name or case number lookup are needed. This must be combined with the “from” and “to” dates of service. Resulting data will appear below the search criteria. Calendar buttons next to the dates of service fields will activate a calendar pop-up feature to aid date selection.
Pricing Page
The Pricing page allows users to inquire on pricing information for procedures and drugs through the Internet. Selecting the radio button for Procedure or Drug will change the available options for searching. A drop-down menu is available for the user to select the associated benefit package and all resulting data will be based on that selection. The search results summary will appear in a list below the criteria. This summary will be hyperlinked to a detail page.
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The detail page for procedure pricing will display all vital procedural components. A field will only appear if data are present for that procedure. Displayed data may include procedure code; allowed amount; PA requirement; maximum units; gender requirement; attachment requirement; lifetime limitation; diagnosis; restriction; or specialty restriction.
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The detail page for drug pricing will display all vital data regarding the drug. A field will only appear if data are present for that drug. Data displayed are NDC Code; EAC; MAC; PA Requirement; maximum units; maximum days supply; age restriction; gender requirement. measurement unit for pharmacy claims; and measurement unit for non-phamacy claims.
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The prior authorization (PA) windows allow the user to submit new PA requests, to inquire about pending prior authorization requests and to inquire/copy notices. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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The PA Submission page allows users to request a prior authorization.
The header section requests information about the patient and provider. Enter appropriate information in boxes. Below the header section is a large summary box that alternates between line items, notes and attachments, depending on the user selection to the left of the summary box. Line item boxes are used to enter procedure-code-related details. The Attachments box is used to enter ACNs to facilitate matching with attachments sent to the OHCA. The Notes box is used as a free form text box for additional information from the provider to OHCA prior auth analysts.
The next section consists of detail boxes. The user enters the appropriate information in the detail boxes and clicks the Add button to move the information to the summary box, which clears the detail box or boxes for additional entries. When complete, click the Submit button.
If required information is missing, the user will be prompted to enter that information and click the Submit button again.
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1. Click on the Prior Authorization link, then click on the Status Inquiry link or move the mouse pointer over the Prior Auth tab, and highlight and click on Inquiry.
2. If you have the PA number, enter it in the PA Number field.
3. If you don‟t have the PA number, you may search for it by entering the client ID number in the Client ID field and enter the assignment code in the Assignment Code field by clicking on the down arrow, highlighting the appropriate choice and clicking on it.
4. You can also search by entering a drug code in the NDC field and/or by entering a date in the Start Date field by typing it in or by clicking on the down arrow to pull up a calendar.
5. Click on the Search button.
A start date can be added to increase the filter. Search results are displayed in a list box of 20 results at a time. If more results exist, they may be viewed by using the Prev. and Next links below the list box. Selecting a result summary line will open the PA detail window.
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The PA Summary page appears when a user searches a PA using the PA Inquiry page. The header section outlines information about the patient and provider. Below the header section is a section that alternates between line items and notes, depending on the user‟s selection to the left of the summary box. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Line item boxes are used to review procedure-code-related details and status. The Reason Code section and I.A.C. section also relates to each line item highlighted in the Line Item summary box.
The Notes box is used to review notes entered to an OHCA PA analyst.
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Go to the Prior Authorization drop-down menu, click on the Notice link and search by one of the following: Client ID or member name to access recent PA notices submitted under your provider number for that member. PA Number of a specific PA. This will bring up only the notices related to that number. Click the Search button and you may view all the PA notices under your provider number. Click on Count Summary to access the Notice image number. This will bring up the PA notice letter, which can be printed.
On each column, the provider can click on the up or down arrow that will allow them to sort ascending or descending order.
AAddddiittiioonnaall ttiiddbbiittss ffoorr ssuucccceessssffuull uussee When searching by either a specific PA number, client ID, or member name the Date Span fields are auto populated with a 60-day span. The From date counts back 60 days from the Through date. The Through date is the day the research is being conducted. The Web program holds a 60-day rolling submission history. For example, if the PA request was entered into the system on 01/01/06, it will be available for online viewing until 03/02/06. When logged on to a Group Provider number, the system will bring up PA information for every provider in that group.
On the Main page of the secure Web site, a message has been added that will tell you the number of unread PA notices under this provider log on.
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Trade Files pages are available to providers to facilitate file transfers between the provider community, drug manufacturers, other involved agencies, and the OHCA.
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The File Upload page allows the user to select a file from a local hard drive and upload it to the OHCA. Users of this feature include Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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providers that wish to upload batch claim submissions and managed care providers that wish to upload PCP information. Batch upload is an Internet submission option that is available to providers who wish to submit large claim batches or inquiries. To use the Batch Upload option, providers must use HIPAA compliant software or clearinghouse/VANs that can submit required data in HIPAA compliant ANSI X12 Addenda format. Once the provider has ensured the batch claim data have been converted into the corresponding HIPAA compliant format and have successfully completed authorization testing with the EDS-EDI team, they then have the ability to upload an entire batch file/transaction into the Oklahoma Medicaid Management Information System (OKMMIS).
If users wish to upload a batch, they must go to the Trade Files page. Pointing at the Trade Files option and clicking on the Upload feature will take them to the Upload page (Screen Sample 5.3).
Screen Sample 5.3
From this page, the user will need to click on the Browse button to locate the file they wish to upload. The user then has the ability to change the file name in the Save as Filename box. Next, click on the drop-down arrow next to the Transaction Type box and pick the appropriate type that corresponds with their transaction. Once all information is complete, the user clicks on the Upload button. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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When the file uploads, the user will see the page stating the upload was successful and the Transaction ID assigned to it (Screen Sample 5.4).
Screen Sample 5.4
The Upload process is now complete for the user. This process must be repeated for all files uploaded via the Web/RAS.
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The File Download page allows the user to select a file from the provider secured Internet site and download it to their system. The available files will be listed as hyperlinked file names. The download process begins when the link is clicked. A compressed or “zipped” file will download to the user‟s system. Compression software is required to open the file. Users of this feature include providers that wish to download batch claims or response files, drug manufacturers that wish to download their invoices and managed care providers that wish to download managed care roster information.
To download a file (i.e., an 835 Remittance Advice), click on the Download feature. The Download page will open. All files that were created for the specific user/provider will be found on this page (Screen Sample 5.5). Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.5
To download one of the listed files, click on the file name. It will either begin to download or a dialog box will open, depending on your browser settings. Download the file according to your usual protocol. The file will automatically download with the default name of “getfile.zip” or “getfile.z,” depending again on your browser.
NOTE: If you are downloading multiple files, you will want to extract the file and rename it before downloading another file to avoid replacing the original “getfile” with your new “getfile.”
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The Account Maintenance page is the first page that users will see when they initialize an account. This page is designed to establish the security credentials for users and clerks, and allows users to update and maintain user account data.
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After users access the Web site for the first time and initialize their account, they are brought to this page. Here users will establish their user names, passwords, contact names and phone numbers. The e-mail field is optional. The security level, status and last logged on dates are maintained by the application and are not updateable by Level I users.
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BBiilllliinngg AAggeenntt oorr CClleerrkk
Adding a billing agent or clerk is done by clicking the Create New Clerk button. A separate box will appear where the new clerk‟s information will be entered.
1. In the User Name field, create a generic name (i.e. CLK12345).
2. In the Contact Name field, enter a valid contact name.
3. In the Password field, enter a generic password (i.e. CLK12345). NOTE: The clerk must replace the generic user name and password with desired selections when they logon the first time.
4. To add all roles, click on the Add All Roles button and skip to Step 7.
5. To add only specific roles, select the role(s) from the list on the right of the screen. To select more than one role, hold the CTRL key while selecting roles.
6. Click on the Grant Role button after selecting the desired role(s). The selected roles appear in the list on the left.
7. To delete a role from the list, highlight the role in the list on the left and click the Cancel Role button. Select the Cancel button to abort the clerk creation process.
8. Click on the Create Clerk button and then the Save button to complete the assignment.
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After a clerk or agent is created, he or she will automatically have access to the provider account under which he or she was created. In order for the clerk or agent to access other providers‟ accounts, access must be granted.
1. Go to the account maintenance section by selecting the Account tab at the top of the page.
2. Key the user name of the clerk or agent to be granted access in the User Name field within the Provider Associations area.
3. To designate the user to receive RAs, rosters, and/or capitation summaries, place a check in the appropriate box(es).
4. Click on the Grant Access To button.
a. Click on the Edit Clerk Roles button to add roles for the existing clerk.
b. To add all roles, press the Add All Roles button.
5. To add only specific roles, select the role(s) from the list on the right of the screen (to select more than one role, hold the CTRL key while selecting roles). Click on the Grant Role button. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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6. Click on the Update Clerk button when all selections are made.
7. Click the Save button when back on the Account page.
NOTE: This process must be followed for each provider account to which the clerk or agent needs access.
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When a billing agent or clerk no longer needs access to your provider account, you must revoke his or her account privileges.
1. Log in as the provider and click on the Account tab at the top.
2. Highlight the user name from the list in the box and click on the Revoke Permissions button.
3. A box will appear asking if this clerk should be revoked access to the account. Select the OK button to complete the process or select Cancel to deny the revocation.
4. After selecting OK, click the Save button.
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The Account Maintenance page for Level IA users operates the same as the above Level I in all aspects, except that the Level IA user will be forced to establish self-authentication questions and answers when the account is initialized. These questions and answers may be updated at any time.
LLeevveell IIII ((CClleerrkk))
The Account Maintenance page for Level II users operates the same as the above Level IA in all aspects – except that the Level II user does not have the ability to create, grant access to, or revoke permissions of other Level II users.
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The Mailbox page contains messages from the OHCA directed specifically to certain groups, such as specialties. After successfully accessing the secure Web site, the Mailbox page displays first. The Mailbox will always display any active messages not checked as read. Next to each message is a Read check box. When this is selected, the message will no longer appear at log on. However, the message will still be available by clicking the Mailbox link from the menu and remains in the Mailbox until it expires. The administrator who sends the message determines the expiration date. Below the messages is the Next button. Selecting this button will take the user to the Main page.
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The Help pages for the secure Web site are dynamic in that the help text that displays is unique to the page that the user is viewing. Help pages also include a button titled, Ask Tech Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Support. This button opens a page that has a text box for asking a question. When you click Send on this page, the text you typed and the .xml file from the Web page you are viewing is sent to a call support specialist for review.
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Clicking the Log Off Tab ends your current session on the secure site and directs you to the Log Off page. The Log Off page displays the non-secure menu options. Clicking the Log Back On button will take you to the Log On page.
SECTION C: REMOTE ACCESS SERVER (RAS)
you may use the Remote Access Server (RAS) to submit claims through an existing dial-up connection. The RAS lets providers use all options of OHCA‟s secure Web site without an Internet service provider. Basic requirements to log on the RAS are an analog phone line, a modem and Internet Explorer 5.0 (or higher).
Screen Sample 5.6
The first step in accessing the RAS is to create a new connection for the Oklahoma Medicaid Remote Access Server (see Screen Sample 5.6). To prompt the Network Connection Wizard
1. click on the Start button on the main toolbar;
2. drag mouse up to Programs;
3. drag mouse over to Accessories;
4. drag mouse over to Communications; and
5. drag mouse over to Network and Dial-up Connections and click on it. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.7
Once you have the Folder opened for Network and Dial-up Connections (see Screen Sample 5.7), click on the “Make New Connection” icon to start the Network Connection Wizard.
Screen Sample 5.8
Once the Network Connection Wizard has started (see Screen Sample 5.8), this box appears and guides the user through the network creation process. The first step in the setup process is to click Next. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.9
In the “Network Connection Type” box, (see Screen Sample 5.9) click on the “Dial-up to private network” option and then click Next. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.10
The “Phone Number to Dial” box (see Screen Sample 5.10) prompts the user to type in the actual phone number they will be using for the new connection. The phone number to type in this box is Area Code: 405, Phone number: 4166859 (Do not include any dashes in the phone number). Then select “United States of America [1] for the Country/Region code selection and put a check in the “Use dialing rules” checkbox. Click the Next button.
Screen Sample 5.11 Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Select For all users on the “Connection Availability” section (see Screen Sample 5.11) of the Network Connection Wizard. This option allows all users on this computer to have access to the RAS. Click the Next button.
Screen Sample 5.12
Finally, assign a name to use for the connection (see Screen Sample 5.12). After typing the new connection name in the specified box, click on the “Add a shortcut to my desktop” check box. This option will create an icon on your computer desktop. This enables you to click on the icon whenever you wish to log on to the RAS. After clicking on the Finish button, all the information needed to access the RAS is saved and stored on your computer. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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AACCCCEESSSSIINNGG TTHHEE RRAASS
Screen Sample 5.13
To access the RAS, double click on the shortcut icon found on the desktop (this icon was created when establishing the RAS Connection Setting through the Setup Wizard) (see Screen Sample 5.13). This launches the Connection Box prompt for the RAS. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.14
In the Connection Box prompt (see Screen Sample 5.14), type in the user name and password. All providers accessing the RAS will use the same default user name and password:
Username: Provider
Password: eds123
After typing the user name and password, check the dial-up number to ensure that your computer will dial the correct number. The RAS dial-up phone number is 405-416-6859 Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Once the dial-up number is validated, click on the Dial button. This will prompt the computer to attempt connection to the RAS (see Screen Sample 5.15).
Screen Sample 5.15
After connecting and username and password authentication is complete, you will see a prompt in the lower right corner of your desktop verifying the connection (see Screen Sample 5.16).
Screen Sample 5.16
After connecting to the RAS, open a Web browser and type https://192.168.100.163/Oklahoma/Security/logon.xhtml into the browser bar.
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Provider Billing And Procedure Provider Billing And Procedure Manual Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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INTRODUCTION
The following information is intended to provide procedures for submitting claims to the OHCA. For information on what services are covered by the Oklahoma SoonerCare program, please access the agency rules. Rules can be found at www.okhca.org. There are three methods for submitting claims to the OHCA: paper, direct data entry (DDE) via Medicaid on the Web and through 837 batch transactions. Below is a paper-to-electronic conversion table for the different claim-submission types. Please refer to the EDI chapter of this manual for instructions on completing the HIPAA transaction types. Paper DDE HIPAA Transactions
1500
Professional
837P
UB 04
Institutional
837I
ADA 2006
Dental
837D
Pharmacy Drug Claim Form
Pharmacy
NCPDP, version 5.1
Compound Prescription Drug Claim Form
Pharmacy
NCPDP, version 5.1
SECTION A: PAPER CLAIM RECOMMENDATIONS
Claim forms are prepared as follows:
1. Enter complete information with a typewriter, personal computer or ballpoint pen (blue or black ink). Do not use red ink.
2. Provide all required information for every claim line. Do not use ditto marks or the words “same as above.”
3. Verify the accuracy of all information before submitting the claim.
4. Follow the instructions for preparing paper claim forms in this chapter.
5. 1500, UB 04, Drug/Compound and ADA 2006 claim forms are scanned into the OKMMIS. Paper claim forms should be submitted on the original red forms to facilitate the scanning process. This applies to 1500 and UB 04 claim forms. If you submit a copy it must be legible.
6. Mail paper claims to the appropriate mailbox address listed in each claim section.
7. The attachments for a claim should be placed under the identified claim for processing. Do not place the attachment on top of the claim form or it will be associated to previously Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 69
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processed claim. If the attachment is stapled to the claim, place one staple in the upper left corner.
OORRDDEERRIINNGG PPAAPPEERR CCLLAAIIMM FFOORRMMSS
UB-04, 1500, and ADA 2006 (dental) claim forms can be ordered from a standard form supply company. HP does not distribute supplies of these forms. Drug and Compound prescription claim forms can be downloaded from the OHCA Web site, ordered by contacting the OHCA Call Center or by writing a request to:
HP Form Request P.O. Box 18650 Oklahoma City, OK 73154-0650 Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 70
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SECTION B: 1500, PROFESSIONAL, 837P Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 71
Revision Date: April 2011
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FFIIEELLDD DDEESSCCRRIIPPTTIIOONN FFOORR 11550000 CCLLAAIIMM FFOORRMM
The 1500 Health Insurance Claim Form (formerly known as the HCFA-1500 and CMS-1500), is the required claim form used by medical providers for professional services, unless otherwise specified. The provider must purchase these forms. This section explains how to complete the paper 1500 claim form.
The form locator chart below indicates which fields are optional, required or required, if applicable. Where necessary, directions applicable to specific provider types are noted. Please mail paper claims to the appropriate mailbox addresses below.
1500 HP Enterprise Services P.O. Box 54740 Oklahoma City, OK 73154
Medicare Crossover (1500 form) HP Enterprise Services P.O. Box 18110 Oklahoma City, OK 73154
Waiver Services HP Enterprise Services P.O. Box 54016 Oklahoma City, OK 73154
HMO Co-Pay/Personal Care Service (individual, not agency) HP Enterprise Services P.O. Box 18500 Oklahoma City, OK 73154
Lab or DME HP Enterprise Services P.O. Box 18430 Oklahoma City, OK 73154
Form Locator 1500 Field Description/Explanation
1
Insurance Location Selection – Enter X for Medicaid. Required.
1a
Insured‟s ID Number – Enter the member‟s SoonerCare identification number. Must be nine digits. Required.
2
Patient‟s Name – (Last name, first name, middle initial) – Enter the member‟s last name, first name and middle initial. Required.
3
Patient‟s Birth Date – Enter the member‟s birth date in MMDDYY format.
Sex – Enter an X in the appropriate box. Optional. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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Form Locator 1500 Field Description/Explanation
4
Insured‟s Name – (Last name, first name, middle initial). Optional.
5
Patient‟s Address - (No., street), CITY, STATE, ZIP CODE, TELEPHONE (Include area code) – Optional.
6
Patient relationship to insured – Optional.
7
Insured‟s Address - (No., street), CITY, STATE, ZIP CODE, TELEPHONE (Include area code) – Optional.
8
Patient Status – Enter X in the appropriate box. Optional.
9
Other Insured‟s Name – Optional.
9a
Other Insured‟s Policy or Group Number – Optional.
9b
Other Insured‟s Date of Birth. Enter the date in MMDDYY format. – Optional.
Sex – Enter X in the appropriate box. Optional.
9c
Employer‟s Name or School Name – Optional.
9d
Insurance Plan Name or Program Name – If other insurance is available, enter the commercial or private insurance plan name. Required, if applicable.
10
Is Patient‟s Condition Related to – Enter X in the appropriate box of each of the three categories. This information is needed to follow-up third party recovery actions. Required, if applicable.
10a
Employment? – (Current or previous) – Check “Yes” or “No” to indicate if the services being billed are employment related. Required, if applicable.
10b
Auto Accident? – Check “Yes” or “No” to indicate if the services being billed are related to an auto accident. Required, if applicable.
Place (State) – Enter the two-character state code. Required, if applicable.
10c
Other Accident? – Check “Yes��� or “No” to indicate if services being billed are related to an accident of another type. Required, if applicable.
10d
Reserved for Local Use – Enter the total dollar amount paid by a primary insurance carrier (for example, 45.00). You do not need to enter a dollar sign ($). Do not put amount paid by Medicare. If the primary insurance carrier did not issue payment, write the words, “Carrier Denied” in this box. A copy of the insurance payment detail or insurance denial must be attached to paper claims. Required, if applicable. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 73
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Form Locator 1500 Field Description/Explanation
11
Insured‟s Policy Group or FECA Number – If the member has more then one private or commercial insurance, follow directions for form locator 9 in this area. Required, if applicable.
11a
Insured‟s Date of Birth. - Optional.
11b
Employer‟s Name or School Name – Optional.
11c
Insurance Plan Name or Program Name – If other insurance is available, enter the commercial or private insurance plan name. Required, if applicable.
11d
Is There Another Health Benefit Plan – Enter X in the appropriate box. Provide additional third, or more private or commercial insurance information on a separate piece of paper using the directions found in form locator 9. Required, if applicable.
12
Patient‟s or Authorized Person‟s Signature. – Optional.
13
Insured‟s or Authorized Person‟s Signature – Optional.
14
Date of Current Injury, Illness, or Pregnancy – Enter the date in a MMDDYY format of the onset of the illness (day of first symptom) or injury (accident). OB claims must indicate the date the member was first seen for the pregnancy. Required, if applicable, or if form locator 10 has a box checked „Yes‟.
15
If Patient Has Had Same or Similar Illness, Give First Date – Enter date in MMDDYY format. Optional.
16
Date Patient Unable to Work in Current Occupation. – Optional.
17*
Name of Referring Physician or Other Source – Enter the name of the referring physician. Required, if applicable.
17a – 17b
Referring physician‟s ID number.
17a (shaded area)
ID Number of Referring Physician – (small box) Enter the two-character qualifier “1D” to indicate the referring provider‟s ID number is a SoonerCare ID number. Optional. (large box) Enter the 10-character referral number from the Referral Form if the member is enrolled in the SoonerCare Choice or Insure Oklahoma Individual Plan programs. Referral form submission with the claim is not required. Required, if applicable. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 74
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Form Locator 1500 Field Description/Explanation
17b (unshaded area)
NPI Number of Referring Physician – Enter the 10-digit National Provider Identifier (NPI) number from the referral form if the member is enrolled in the SoonerCare Choice or Insure Oklahoma Individual Plan programs. Referral form submission with the claim is not required. Optional.
18
Hospitalization Dates Related to Current Service – Enter the requested FROM and TO dates in MMDDYY format. Required, if applicable.
19
Reserved for Local Use – Optional.
20
Outside Lab– Enter X in the appropriate box. Optional
$ CHARGE – Eight-digit numeric field. Optional.
21.1 to 21.4
Diagnosis Nature of Illness or Injury – Enter the diagnosis codes in order of importance: (1) primary; (2) secondary; (3) tertiary; (4) quaternary. These indicators will correspond to the appropriate procedures and be listed in box 24E as 1, 2, 3 or 4. Required, if applicable.
22
SoonerCare Resubmission Code, Original Ref No. – Optional.
23
Prior Authorization Number – The prior authorization (PA) number is not required as the information is systematically verified. Optional.
The CLIA certification number is required to be put in this block when billing for laboratory services. Required, if applicable. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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Form Locator 1500 Field Description/Explanation
24 a – j (shaded area)
24a - Enter NDC qualifier “N4” followed by the 11-digit NDC number in 24a. For example: N499999999999.
The NDC should be placed in shaded area above the corresponding HCPCS codes (refer to 24d unshaded area for additional instructions).
Do not enter any spaces or dashes.
24b and 24c – Do not enter any information in these fields.
24d - Enter the unit of measure of “UN” for unit, “F2” for international unit, “ML” for milliliter or “GR” for gram followed by the metric decimal quantity. For example: UN103.50. Do not use spaces or dashes and do not include a description or any information beyond what is indicated above.
24e through 24i – Do not enter any information in these fields.
24j - Enter the nine-digit, one alpha character SoonerCare legacy number in 24j. For example: 100200300A (needs to be fictitious # such as 999999999A)
Required, if applicable.
24 (unshaded area)
Detail service lines should be listed in the unshaded areas of 24a - 24j. A maximum of six service lines are allowed per claim.
24a (unshaded area)
Date of Service – Enter FROM and TO dates in MMDDYY format for the billing period for each service rendered. Six detail lines are allowed per form. Required. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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Form Locator 1500 Field Description/Explanation
24b (unshaded area)
Place of service – Enter the place of service code for the place services were rendered. Required.
Place of Service Codes
Code
Description
11
Office
12
Home
20
Urgent care facility
21
Inpatient hospital
22
Outpatient hospital
23
Emergency room
24
Ambulatory surgical center (ASC)
25
Birthing center
26
Military treatment facility
31
Skilled nursing facility (SNF)
32
Nursing facility (NF)
33
Custodial care facility
34
Hospice
41
Ambulance – land
42
Ambulance – air or water
51
Inpatient psychiatric facility
52
Psychiatric facility – partial hospitalization
53
Community mental health center
54
Intermediate care facility for the mentally retarded (ICF/MR)
55
Residential substance abuse treatment facility
56
Psychiatric residential treatment center
61
Comprehensive inpatient rehabilitation facility
62
Comprehensive outpatient rehabilitation facility
65
End-stage renal disease treatment facility
71
State or local public health clinic
72
Rural health clinic (RHC)
81
Independent laboratory
99
Other unlisted facility
24c (unshaded area)
EMG - Emergency indicator. If services are related to an emergency, enter „Y‟. If not, enter „N‟. Optional. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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Form Locator 1500 Field Description/Explanation
24d (unshaded area)
Procedures, Services, or Supplies
CPT/HCPCS – Enter the appropriate procedure code for the service rendered. Only one procedure code is billed on each claim form detail line. If your procedure code requires an NDC, enter the appropriate HCPCS code and refer to 24 a-j shaded area for additional instructions. Required.
Modifier – Enter the appropriate modifier, as applicable. Up to four modifiers can be entered for each detail line. Required, if applicable.
24e (unshaded area)
Diagnosis Pointer – Enter the numeric codes (1, 2, 3 or 4), in order of importance, which correspond to the diagnosis code listed in form locator 21. A minimum of one and maximum of four diagnosis code pointers can be entered on each line. Do not enter the full diagnosis code. Required, if applicable.
24f (unshaded area)
$ Charges – Enter the charges for each line item on the claim form. Required.
24g (unshaded area)
Days or Units – Enter the appropriate number of units of services provided for the procedure code. Whole and decimal numbers are acceptable. Required.
24h (unshaded area)
EPSDT Family Plan –If the services being provided are related to an EPSDT visit, enter „Y‟. If not, enter „N‟ or leave blank. If a „Y‟ is entered, the two-digit EPSDT code must be entered in the shaded area above the box. Required, if applicable.
24h (shaded area)
EPSDT Family Plan – If a „Y‟ is entered in the unshaded area of box 24h, enter the two-digit referral type in this box. Appropriate codes are:
NU – Not Available
AV – Available, Not Used
ST – New Services Requested
S2 – Under Treatment
24i – 24j
When entering the rendering provider‟s ID number, only use the shaded areas of 24i – 24j. When entering the Providers NPI number, use the unshaded area of 24j.
24i (shaded area)
ID Qual. – Enter the two-character qualifier, indicating the type of provider number being used for the rendering provider. Enter „1D‟ to indicate the type of provider number used is for Oklahoma SoonerCare. Optional. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 78
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Form Locator 1500 Field Description/Explanation
24j (shaded area)
Rendering Provider ID # - Enter the 10-character Oklahoma SoonerCare provider number of the rendering provider. This field can be left blank if billing and rendering numbers, including location code, are identical. Required, if applicable.
24i (unshaded area)
ID Qual – This area is already populated with „NPI,‟ indicating that the provider number listed for the rendering provider is the NPI.
24j (unshaded area)
Rendering Provider ID # - Enter the rendering provider‟s 10-digit NPI. Optional.
25
Federal Tax ID Number – Optional.
26
Patient‟s Account Number – Enter the internal patient tracking number. If the account number is supplied, it will appear on the remittance advice. Optional.
27
Accept Assignment? – Oklahoma SoonerCare only accepts assigned claims. Required.
28
Total Charges– Enter the total of column 24f charges. Each page must have a total. Claims cannot be continued to two or more pages. Required.
29
Amount Paid – Enter the amount paid by the member. Required, if applicable.
30
Balance Due– Field 28, TOTAL CHARGE
BALANCE DUE. Required.
31
Signature of Physician or Supplier– The name of the authorized person, someone designated by the agency or organization and the date the claim was created. A signature stamp is acceptable; however, the statement “Signature on File” is not allowed. Required.
DATE – Enter the date the claim was filed. Be sure not to write any portion of the date outside of the designated box. The date billed must be on or after the date(s) of service. Required.
32
Name and Address of Facility Where Services Were Rendered - Enter the provider‟s name and address if other than home office. Optional.
32a
Enter the 10-digit NPI number of the facility where the services were rendered. Optional.
32b
Enter the two-character qualifier “1D” and 10-character Oklahoma SoonerCare provider ID number of the facility where the services were rendered. No spaces or dashes should be used. Optional. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 79
Revision Date: April 2011
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Form Locator 1500 Field Description/Explanation
33
PHYSICIAN‟S SUPPLIER‟S BILLING NAME, ADDRESS, ZIP CODE, & PHONE # - Enter the name, address, zip code and telephone number of provider requesting payment for services listed on claim form. If the provider furnished the services as part of a group practice organization, enter the name, address, zip code and telephone number of the group practice organization. Required.
33a
Enter the 10-digit NPI number of the physician or group. Optional.
33b
Enter the 10-character Oklahoma SoonerCare provider ID number of the billing provider. No spaces or dashes should be used. Required. (Use of the 1D Medicaid qualifier is optional)
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Use the Professional claim form example and directions below as guides when submitting claims through DDE on Medicaid on the Web. To open the form, choose the „Submit Professional‟ (see Screen Sample 6.1) claim option from the Claims.
NOTE: Medicare denials and crossover claims cannot be billed through the Secure Site using DDE as they are required to be billed on paper.
Screen Sample 6.1 Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 80
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Screen Sample 6.2 Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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Screen Sample 6.2 continued
DDE Professional Claim Submission Instructions
Billing Information
Provider ID - Provider Number - Your Provider ID should appear in the first box. Verify it is correct. If it is not, you may need to log out and access the correct provider. Required.
Client ID - Enter the member‟s Oklahoma SoonerCare ID number in the Client ID field. (The patient‟s last and first name will auto populate when the member‟s ID number is in the system.) Required.
Patient Account # - The Patient account number will be captured and appear on the remittance advice, if entered into this field. Optional.
Referring physician - Enter the 10-character referral number from the referral form, if the member is enrolled in the SoonerCare Choice program. Required, if applicable. See 1500 form locator 17A.
Service Information
From Date - Enter the from date of service into the From Date field. Required.
To Date - Enter the to date of service into the To Date field. Required.
Expected Delivery Date - Enter the expected delivery date into the Expected Delivery Date field. Required, if applicable. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 82
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DDE Professional Claim Submission Instructions
Accident Related To - If claim is related to an accident, select accident type in the Accident Related To field. Required, if applicable.
Diagnosis - Select appropriate diagnosis type in the Diagnosis field by choosing from the drop-down menu. Enter the diagnosis code(s). DO NOT ENTER DECIMALS. Required.
See 1500 form locator 24 for more information.
Charges
Total Charges - Total Charges field is automatically populated.
TPL Amount - Enter the amount paid by any other insurance. If no other insurance is involved or has paid on this claim, leave this field at 0.00. Required, if applicable.
Carrier Denied – If there is other insurance involved and the primary carrier denied the charges, or allowed coverage but did not make a payment (for example: applied to deductible), select ��Yes.‟ If the primary carrier made a payment or if there is no other insurance involved, select „No.��� Required, if applicable.
Detail Information
From DOS - Enter the from date of service in the From DOS field. This will auto-populate from the line detail. Required.
To DOS - Enter the to date of service in the To DOS field. This will auto-populate from the line detail. Required.
POS - Select the place of service code using the drop-down window. Required.
Procedure - Enter the CPT or HCPCS procedure code in the Procedure field. See 1500 form locator 24d for more information. Required.
Modifier - Enter modifier code(s) in the Modifier field(s). Required, if applicable.
Diag. Cross-Ref - Enter the numeric codes (1, 2, 3 or 4), in order of importance, which correspond to the diagnosis code listed in form locator 21. A minimum of one and maximum of four diagnosis code pointers can be entered on each line. Do not enter the full diagnosis code and do not use commas. Required, if applicable.
Units - Enter number of units billed in the Units field. Required.
Charges - Enter the total dollar amount of charges for that specific detail in the Charges field. This action will auto-populate the Total Charges field. Required.
Pregnancy? - If claim is related to a pregnancy, check the Pregnancy? box. Required, if applicable.
Emergency? - If claim is related to an emergency, check the Emergency? box. Required, if applicable. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 83
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DDE Professional Claim Submission Instructions
EPSDT - If claim is related to an EPSDT service, select the appropriate referral type from the drop-down list. If nothing is entered, this field will default to „No‟. Required, if applicable.
Rendering Physician – If different from the billing provider number, enter the rendering physician‟s SoonerCare ID number and location code in the Rendering Physician field. This is the rendering provider and is not necessarily a physician. Required, if applicable.
If additional items are to be billed on this submission, click the Add button next to the line item window and repeat process. Click the Remove button to remove a line entry.
Hard Copy Attachments
If a hard-copy attachment is to be added, use the Hard-Copy Attachments arrow at the end of the bar.
Enter an attachment control number as assigned by the provider in the Attachment Control Number field.
The transmission code is entered in the Transmission Code field by clicking on the down arrow, highlighting the appropriate code and clicking on it.
Report type code can be entered into the Report Type field by clicking on the down arrow to make the selection.
Free form text can be entered into the Description field.
Complete form HCA-13 “Paper Attachment to Electronic Claims,” and mail or fax the attachment control number form. See Section F in this chapter for instructions on completing form HCA-13.
Attachment control numbers cannot be made up of special characters or include spaces.
Required, if applicable.
Submit - When finished, click on the Submit button. Required. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 84
Revision Date: April 2011
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SECTION C: UB 04, INSTITUTIONAL, 837I Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 85
Revision Date: April 2011
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FFIIEELLDD DDEESSCCRRIIPPTTIIOONNSS FFOORR TTHHEE UUBB--0044 CCLLAAIIMM FFOORRMM
The UB-04 Universal Billing Claim Form, is used to bill for facility services cov

Revision History The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 2
Revision Date: April 2011
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Revision History The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 3
Revision Date: April 2011
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Revision History
Version
Revision Date
Revision Page Number(s)
Reason
Reviser
2.0
Feb. 2005
All
Annual revision
Publications
2.1
March 2005
8-15
Added Acronyms
Publications
3.0
June 2005
64, 65, 121, 151 - 154
Redaction
Publications
3.1
Oct. 2005
127
Redaction
Publications
3.2
Jan. 2007
All
2006 annual update
Publications
3.3
Aug. 2007
All
2007 annual update
Publications
3.4
Dec. 2007
All
Redaction
Publications
3.5
July 2008
54 – 57
CO 8766 - Redaction
Publications
3.6
Oct. 2008
178 - 182
OHCA ordered
Publications
3.7
Dec. 2008
26 – 38, 313
Medical Home updates
Publications
3.8
Feb. 2011
74, 77, 82, 89, 90, 95
Redaction
Publications
3.9
April 2011
91
Redaction
Publications Revision History The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 4
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Table of Contents The OHCA Provider Billing And Procedure Manual
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Table of Contents
Chapter 1 General Information ............................................................... 9
Introduction ............................................................................................... 10
Section A: OHCA Web site ..................................................................... 10
Section B: General Contact Information: ................................................. 12
Chapter 2 SoonerCare Programs .......................................................... 15
Introduction ............................................................................................... 16
Section A: Provider Policies .................................................................... 16
Section B: Provider File Maintenance ...................................................... 17
Section C: Provider Services .................................................................... 17
Section D: Written Inquiries .................................................................... 23
Chapter 3 SoonerCare Choice ............................................................... 24
Introduction ............................................................................................... 25
Section A: Covered Members .................................................................. 26
Section B: Access to Care ........................................................................ 27
Section C: Member Enrollment/Disenrollment ....................................... 28
Section D: Referrals ................................................................................. 30
Section E: EPSDT .................................................................................... 32
Section F: Reporting Requirements ......................................................... 33
Section G: Reimbursement ....................................................................... 33
Section H: Provider Resources ................................................................ 34
Chapter 4 Member Eligibility Verification .......................................... 37
Introduction ............................................................................................... 38
Section A: Member ID Card ..................................................................... 38
Section B: Options to Verify Member Eligibility ..................................... 38
Chapter 5 Web/RAS ............................................................................... 42
Introduction ............................................................................................... 43
Section A: Accessing The Secure Web Site ............................................ 43
Section B: Web Features .......................................................................... 48
Section C: Remote Access Server (RAS) ................................................ 59
Chapter 6 Claim Completion ................................................................. 67
Introduction ............................................................................................... 68
Section A: Paper Claim Recommendations .............................................. 68
Section B: 1500, Professional, 837P ......................................................... 70
Section C: UB 04, Institutional, 837I........................................................ 84
Section D: ADA 2006, Dental, 837D ....................................................... 97
Section E: Drug/Compound Prescription Drug , Pharmacy, NCPDP .... 107
Section F: Electronic Claim Filing Attachment Filing ........................... 116
Section G: Medicare-Medicaid Crossover Invoice ................................. 118
Chapter 7 Electronic Data Interchange ............................................. 121
Introduction ............................................................................................. 122
Section A: Professional Claims (837 Professional) ............................... 123
Section B: Institutional Claims (837 Institutional) ................................ 124
Section C: Dental Claim (837 Dental) ................................................... 124
Section D: Pharmacy Claims .................................................................. 125
Section E: Claim Inquiries/Responses .................................................... 125 Table of Contents The OHCA Provider Billing And Procedure Manual
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Section F: Eligibility Inquiries/Responses .............................................. 126
Section G: Remittance Advice (RA)....................................................... 127
Section H: Electronic Claims or Prior Authorizations with Paper Attachments ............................................................................................ 127
Section I: Electronic Media Types .......................................................... 128
Section J: HIPAA transaction and code set requirements ..................... 129
Chapter 8 Claims Resolution Process ................................................. 130
Introduction ............................................................................................. 131
Section A: Claim Creation ..................................................................... 131
Section B: Data Entry ............................................................................ 132
Section C: Resolutions ........................................................................... 133
Chapter 9 Paid Claim Adjustment Procedures.................................. 136
Introduction ............................................................................................. 137
Section A: Adjustment Categories .......................................................... 137
Section B: Adjustment Types and Workflow ........................................ 140
Chapter 10 Indian Health Services ..................................................... 141
Introduction ............................................................................................. 142
Section A: SoonerCare Eligibility .......................................................... 142
Section B: Contract Health Services ....................................................... 142
Chapter 11 Pharmacy ........................................................................... 143
Introduction ............................................................................................. 144
Chapter 12 Insure Oklahoma .............................................................. 147
Introduction ............................................................................................. 148
Section A: What is the Insure Oklahoma Individual Plan? ................... 148
Section B: Insure Oklahoma Individual Plan Billing Procedures .......... 150
Chapter 13 Long Term Care Nursing Facilities ............................... 151
Introduction ............................................................................................. 152
Section A: LTC Nursing Facility Provider Eligibility ............................ 152
Section B: Pre-admission Screening And Resident Review Process (PASRR) ................................................................................................. 152
Section C: ICF/MR Process .................................................................... 152
Section D: Member Level Of Care Appeals Process .............................. 153
Section E: Billing Considerations ........................................................... 153
Chapter 14 Third Party Liability ........................................................ 154
Introduction ............................................................................................. 155
Section A: Services Exempt from Third Party ....................................... 157
Section B: Third Party Liability Claim Processing Requirements ......... 158
Section C: Coordination with Commercial Plans ................................... 161
Section D: Medicare-OHCA Related Reimbursement ........................... 162
Section E: Member Third Party Liability Update Procedures ................ 164
Chapter 15 Prior Authorization .......................................................... 168
Introduction ............................................................................................. 169
Section A: Prior Authorization Requests ............................................... 169
Section B: Prior Authorization Process .................................................. 171
Section C: Reconsideration and Appeal Procedures .............................. 172
Section D: Home & Community-Based Services (HCBS) §1915(c) WAIVER Prior Authorizations ............................................................... 174 Table of Contents The OHCA Provider Billing And Procedure Manual
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Chapter 16 Financial Services ............................................................. 175
Introduction ............................................................................................. 176
Section A: Payment Information ........................................................... 176
Section B: Paper RA .............................................................................. 177
Section C: Electronic Remittance Advice .............................................. 303
Section D: 1099 & W-2s ........................................................................ 303
Section E: Stop Payments, Voids, Re-issuance ..................................... 303
Section F: Electronic Care Coordination Payments ............................... 304
Chapter 17 Utilization Review ............................................................. 309
Introduction ............................................................................................. 310
Section A: Provider Utilization Review ................................................ 311
Section B: Member Utilization Review ................................................. 312
Section C: Utilization Review Trends ................................................... 313
Section D: Administrative Review and Appeal Process ........................ 314
Chapter 18 Quality Assurance And Improvement ........................... 315
Introduction ............................................................................................. 316
Section A: Provider Utilization Review ................................................ 316
Section B: On-Site Provider Audits ....................................................... 317
Section C: Member or Provider Complaints .......................................... 318
Section D: Quality Improvement Studies/Projects ................................ 318
Section E: System Integrity ................................................................... 319
Chapter 19 Forms ................................................................................. 321
Introduction ............................................................................................. 322
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INTRODUCTION
The Oklahoma Health Care Authority (OHCA) is the state agency responsible for the administration of the Oklahoma Medicaid program. The OHCA has a contractual agreement with Electronic Data Systems (EDS) to be the fiscal agent for the Oklahoma Medicaid program. The OHCA‟s primary objective is to maintain a system to accurately and effectively process and pay all valid Oklahoma Title XIX Medicaid program provider claims.
This publication is the primary reference for submitting and processing claims, prior authorization requests, remittance advice and other related documents. This manual is not a legal description of all aspects of Medicaid law. This manual is intended to provide basic program guidelines for providers that participate in the Oklahoma Medicaid program.
A provider‟s participation in the Oklahoma Medicaid program is voluntary. However, providers that chose to participate in Medicaid must accept the Medicaid payment as payment in full for services covered by Medicaid. The provider is restricted from charging the Medicaid member the difference between the usual and customary charge, and Medicaid‟s payment. Services not covered under the Medicaid program can be billed directly to the member. If there are any instances where the guidelines appear to contradict relevant provisions of the Oklahoma Medicaid policies and rules, the policies and rules will prevail. This manual does not take precedence over federal regulation, state statutes or administrative procedures. The OHCA and EDS developed this manual for Oklahoma Medicaid providers.
The Provider Billing And Procedure Manual will receive periodic reviews, changes and updates. The online version of this manual is the most current version and is available at the OHCA Web site at http://www.okhca.org. Once there, click on Provider, Policies & Rules, scroll down to Guides & Manuals and click on the OHCA Provider Billing & Procedure Manual. Providers issued print and CD copies of this manual will not automatically receive an updated version.
SECTION A: OHCA WEB SITE
The OHCA administers the state of Oklahoma‟s Medicaid agency program known as “SoonerCare.” Primary programs under SoonerCare include: SoonerCare Traditional, SoonerCare Choice and Sooner Plan. The OHCA Web site at http://www.okhca.org (see screen sample 1.1) provides information for Medicaid members and providers with data on programs, and health and medical policies. Chapter 1: General Information The OHCA Provider Billing And Procedure Manual
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Screen sample 1.1
OOHHCCAA WWEEBB PPAAGGEESS
Calendar: The Calendar page can be used to find dates and details on training, meeting and other upcoming events.
Contact Us: Use the Contact Us page to find everything from OHCA addresses and telephone numbers to driving directions to the OHCA office.
Provider: The Provider page has information on becoming a Medicaid provider, provider-type details, claim management tools, program reference resources, rule and policy data, free training opportunities, and updates on what is new in SoonerCare.
Publications: The Publications page has links to most OHCA publications, forms, and OHCA information on statistical reports and data. Chapter 1: General Information The OHCA Provider Billing And Procedure Manual
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SECTION B: GENERAL CONTACT INFORMATION:
OOHHCCAA CCaallll TTrreeee
Toll free: 800-522-0114, or in Oklahoma City area: 405-522-6205 Option Unit Call Types Availability 1 OHCA Call Center Claim status, eligibility inquiries or policy questions 7:30 am – 5:30 pm M-F
2, 1
Internet Help Desk
Internet PIN resets or assistance with Medicaid on the Web
8 am – noon & 1pm – 5 pm M-F 2, 2 EDI Help Desk Batch transactions assistance 8 am – noon & 1pm – 5 pm M-F
3, 1
Adjustments
Paid claim adjustments or outstanding A/R inquiries
7:30 am – 4 pm M, W, Th, F
12 p.m. – 4 p.m. Tues. (Training) 3, 2 Third Party Liability Health insurance injury/accident questionnaires, third party insurance inquiries, estate recovery or subrogation issues 8 am – 5 pm M-F 4 Pharmacy Help Desk (issues) Pharmacy issues 8:30 am – 7 pm M-F 9 am – 5 pm Sat. 11 am – 5 pm Sun. 5 Provider Contracts Provider contracts 8:30 am – 4:30 pm M, T, Th, F 12:00 pm- 4:30 pm Wed. (Training) 6, 1 Pharmacy Help Desk (authorizations) Pharmacy authorizations 8:30 am – 7 pm M-F 9 am – 5 pm Sat. 11 am – 5 pm Sun. 6, 2 Behavioral Health Authorization Behavioral Health authorizations 8 am – 5 pm M-F 6, 3 Medical Authorizations (status) Medical authorization status 7:30 am – 5:30 pm M-F 6, 4 Medical Authorizations (PA requests) Prior authorization requests for DME, medical services and emergency PAs for aliens 8 am – 5 pm M-F Closed 10 am – 1 pm Tue.
6, 5
Dental Authorizations
Dental authorizations
8 am – 5 pm M-F Chapter 1: General Information The OHCA Provider Billing And Procedure Manual
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CCLLAAIIMM MMAAIILLIINNGG AADDDDRREESSSS::
EDI Mail tapes, CDs and diskettes to: EDS P.O. Box 54400 OKC, OK 73154
Form UB-04 (Hospital or Home Health) Lab or DME (1500) EDS P.O. Box 18430 OKC, OK 73154
Form 1500 EDS P.O. Box 54740 OKC, OK 73154
HMO Co-pay/Personal Care (Individual; not agency) EDS P.O. Box 18500 OKC, OK 73154
Medicare Crossovers, Dental (ADA form), (1500) EDS P.O. Box 18110 OKC, OK 73154
Pharmacy EDS P.O. Box 18650 OKC, OK 73154
Waiver provider billing for waiver services P.O. Box 54016 OKC, OK 73154
Refunding money or returning check OHCA-Finance Unit P.O. Box 18299 OKC, OK 73154
Sending a written inquiry with copy of claim OHCA-Provider Services P.O. Box 18506 OKC, OK 73154
Long Term Care Nursing Facilities EDS P.O. Box 54200 OKC, OK 73154
Claim adjustment request OHCA-Adjustment Unit 4545 N.Lincoln Blvd Suite 124 OKC, OK 73105
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INTRODUCTION
In order to be eligible to participate in Oklahoma SoonerCare programs, providers must have an approved provider agreement on file with the OHCA. Through this agreement, the provider certifies all information submitted on claims is accurate and complies with all applicable state and federal regulations. This agreement is effective once the provider signs the agreement, and the OHCA reviews and approves the agreement.
SECTION A: PROVIDER POLICIES
A provider is any individual or facility that qualifies and meets all state and federal requirements, and has a current agreement with the OHCA to provide health-care services under SoonerCare or other OHCA-administered medical service programs.
PPAAYYMMEENNTTSS
Payments to providers under SoonerCare are made for services identified as personally rendered services performed on behalf of a specific patient. There are no exceptions to personally rendered services unless specifically set out in coverage guidelines.
Payments are made on behalf of SoonerCare eligible individuals for services within the scope of the OHCA‟s medical programs. Services cannot be paid under SoonerCare for ineligible individuals, services not covered under the scope of medical programs or services not meeting documentation requirements. These claims will be denied or payment will be recouped, in some instances upon post-payment review.
LLIINNKK UUPP TTOO TTHHEE OOHHCCAA
For additional information on provider policies, go to www.okhca.org, click on the Policies & Rules link (see Screen Sample 2.1). When the page appears, select the Oklahoma Health Care Authority Medical Rules link and select Chapter 30. Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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Screen Sample 2.1
SECTION B: PROVIDER FILE MAINTENANCE
Provider agreements must be renewed every three years. It is the responsibility of the provider to maintain records and agreements with the OHCA.
All information changes including address, phone number, bank (including electronic funds transfer data) and group member changes must be promptly reported. Failure to maintain current provider information can result in delay or denial of payments for services rendered. Changes for all provider record information should be in writing and signed by the provider. Please mail your request to:
Oklahoma Health Care Authority
Attention: Provider Enrollment
P.O. Box 54015
Oklahoma City, OK 73154
For additional information on provider enrollment criteria, call the OHCA toll-free in state at 800-522-0114 (option 5), or out of state at 405-522-6205 (option 5). You can also go to www.okhca.org, click on Enrollment, New Contracts and select the appropriate option.
SECTION C: PROVIDER SERVICES
EELLIIGGIIBBIILLIITTYY VVEERRIIFFIICCAATTIIOONN SSYYSSTTEEMM ((EEVVSS))
The EVS system is available from 5 to 1 a.m. Access information by entering the provider‟s SoonerCare ID number and the alpha-character location code. Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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The automated voice response (AVR) system provides a nationwide toll free telephone number to help providers obtain pertinent information. Providers are able to enter information on a touch-tone phone or by the AVR speech application.
AAvvaaiillaabbllee SSeerrvviicceess
The following is a list of information that can be obtained through the AVR: Member eligibility with fax back capabilities. Provider warrant information. Prior authorization with fax back capabilities. Claim status inquiry.
More information regarding the EVS can be found in the Member Eligibility Verification chapter of this manual
EEVVSS PPhhoonnee NNuummbbeerrss
Nationwide toll free: 800-767-3949
Oklahoma City metro area: 405-840-0650
CCOOMMPPUUTTEERR TTEELLEEPPHHOONNYY IINNTTEEGGRRAATTIIOONN
Computer Telephony Integration (CTI) allows providers to enter information - such as name, provider number and location - through the AVR system. The information is captured and sent to the appropriate provider service coordinator. The provider representative enters notes and questions from the provider into the call tracking system, so if a call must be transferred the provider‟s information will be captured and available to the next representative.
CCAALLLL CCEENNTTEERRSS
The OHCA is committed to providing customer service to the provider community, members and other interested parties. OHCA Call Center representatives answer inquiries regarding claim status, eligibility, warrant information, proper billing procedures, prior authorization and SoonerCare policy for providers as well as members. Complex claims and written correspondence are some of the types of inquiries addressed by the OHCA Provider Service Coordinators.
OHCA Services closely interacts with the EDS Provider Relations staff to resolve training issues related to the Oklahoma SoonerCare program. Provider Services and EDS Provider Relations act as intermediaries for providers, members and others by resolving billing or adjudication problems requiring additional information or research.
PPRROOVVIIDDEERR IINNQQUUIIRRIIEESS
Telephone inquires are received between 7:30 a.m. and 5:30 p.m., Monday through Friday. (Pharmacy Help Desk is available extended hours seven days/week.) Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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AAvvaaiillaabbllee SSeerrvviicceess
Information available to the provider through the call tree options include: Claim status. Eligibility/EVS. Pharmacy Help Desk. Provider Contracts. Adjustments. Third Party Liability (TPL). PIN resets. Prior Authorization.
o Medical.
o Dental.
BBeeffoorree YYoouu CCaallll
When calling OHCA Provider Services or the OHCA Call Center, have the following information available to expedite the research of the inquiry:
 The 10-character (nine numbers, alpha character) SoonerCare provider number.
 The SoonerCare member‟s ID number.
 The date(s) of service.
 The billed amount.
MMEEMMBBEERRSS IINNQQUUIIRRIIEESS
When inquiring by telephone, please call between 7:30 a.m. and 5:30 p.m., Monday through Friday.
PPhhoonnee NNuummbbeerrss
Members toll-free: 800-522-0310
Metro Area: 405-522-7171
AAvvaaiillaabbllee SSeerrvviicceess
Information available for the members through the call tree options include: Eligibility. Claim status. SoonerCare Member Services. Pharmacy Help Desk Enrollment Agent. Patient Advice Line, 5 p.m. – 8 a.m. M-F, 24 hours daily on holidays and weekends when Help Line is closed. Spanish assistance, 7:30a.m. – 5:30 p.m. M-F.
EEDDSS FFIIEELLDD CCOONNSSUULLTTAANNTTSS
EDS has a team of regional field consultants with in-depth knowledge of Oklahoma SoonerCare billing requirements and claim-processing procedures. Training is offered on billing, EVS Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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and AVR, Electronic Data Interchange (EDI) and Medicaid on the Web Secure Site. Field consultants provide training through on-site visits and workshops. They encourage providers to use electronic claim submission because it‟s fast, easy to use and saves money.
TTrraaiinniinngg OObbjjeeccttiivveess
The focus of a field consultant is to
1. train newly enrolled providers;
2. contact and visit high-volume providers; and
3. conduct provider training workshops.
Providers may contact their field consultant by telephone to request a visit for training at the provider‟s location. Field consultants are responsible for arranging their own schedules. They are available Tuesday through Thursday for onsite provider visits. Provider on-site visits are normally scheduled two weeks in advance. Since field consultants are often out of the office, please allow a minimum of 48 hours for telephone calls to be returned.
NOTE: Field consultants are the last resource for any claim inquiry questions. For claim research or resolution of other Oklahoma SoonerCare issues, contact the OHCA Call Center at 800-522-0114 or 405-522-6205.
PPrroovviiddeerr WWoorrkksshhooppss
Field consultants are responsible for the development and presentation of educational workshops about all procedural aspects of the Oklahoma Medicaid Management Information System (OKMMIS).
The OHCA presents scheduled workshops throughout the year to educate providers on Oklahoma SoonerCare claim processing procedures. Workshops are announced in bulletins, newsletters and on the OHCA Web site at http://www.okhca.org. Group training can also be arranged at the request of individual provider groups or associations.
BBee PPrreeppaarreedd
The following information should be provided to assist your field consultant in planning the visit or workshop:
 Provider type and specialty attending the seminar.
 Number of attendees.
 Time and location of the event.
 Issues to be addressed.
 Point of contact, in case additional information is needed prior to the event. Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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Region
Phone Number
Counties within the Region
I
405-416-6715
Alfalfa, Beaver, Cimarron, Dewey, Ellis, Garfield, Grant, Harper, Kay, Kingfisher, Lincoln, Logan, Major, Noble, Payne, Pottawatomie, Texas, Woods, Woodward
II
405-416-6739
Adair, Cherokee, Craig, Creek, Delaware, Mayes, Muskogee, Nowata, Osage, Ottawa, Pawnee, Rogers, Sequoyah, Wagoner, Washington
III
405-416-6720
Beckham, Blaine, Caddo, Canadian, Cleveland, Comanche, Cotton, Custer, Garvin, Grady, Greer, Harmon, Jackson, Jefferson, Kiowa, McClain, Roger Mills, Stephens, Tillman, Washita
IV
405-416-6763
Atoka, Bryan, Carter, Choctaw, Coal, Haskell, Hughes, Johnston, Latimer, LeFlore, Love, McCurtain, McIntosh, Marshall, Murray, Okfuskee, Okmulgee, Pittsburg, Pontotoc, Pushmataha, Seminole
V
405-416-6740
Oklahoma County
VI
405-416-6716
Tulsa County
Out-of-state consultant: 405-416-6730
Field staff supervisor: 405-416-6768
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MMEEDDIICCAAIIDD OONN TTHHEE WWEEBB//SSEECCUURREE SSIITTEE
Medicaid on the Web is the OHCA‟s secure Web site, offering providers a number of services from submitting claims on the Web to fast verification of claim status. New providers are assigned a PIN to access the Web site.
To access the page, go to www.okhca.org, click on the Provider tab and choose Secure Site from the drop-down menu. For more information on logging in for the first time and entering the secure site, look under the Help tab on the Web site. Medicaid on the Web is available from 5 to 1 a.m.
AAvvaaiillaabbllee SSeerrvviicceess
The following services are available to Medicaid on the Web users: Global messaging (can be specific to one or all providers). Claims submission. Claims inquiry. Prior authorization submission. Provider PA notice. Prior authorization inquiry. Procedure pricing. Financial warrant amount. Eligibility verification. Managed Care rosters. Chapter 2: SoonerCare Programs The OHCA Provider Billing And Procedure Manual
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SECTION D: WRITTEN INQUIRIES
When inquiring in writing about the status of a SoonerCare claim, use the SoonerCare Claim Inquiry/Response form HCA-17. A sample of this form is found in the Forms chapter of this manual. Follow the instructions on the form. Attach a copy of the original claim and any supporting documentation, such as a copy of the remittance/denial, PCP/CM referral, Medicare EOMB, consent forms or medical records required for review.
Mail Inquiry/Response forms, policy questions and any other written correspondence regarding hard-to-resolve SoonerCare claims to:
The OHCA
Attention: Provider Services
P.O. Box 18506
Oklahoma City, OK
73154-0506
MMAAIILLIINNGG CCLLAAIIMMSS
Original, corrected and re-filed claims are submitted to the fiscal agent at the appropriate address listed in the General Information chapter of this manual. Claims mailed to addresses other than the assigned P.O. Box might result in payment delays. For a list of mailing addresses, see the General Information chapter of this manual.
Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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INTRODUCTION
SoonerCare Choice is Oklahoma‟s Medicaid Managed Care program. The program began in 1996 in 61 rural counties in Oklahoma. It was expanded statewide in April 2004 to include urban counties that had been previously covered under the SoonerCare program. The Choice program provides primary and preventive health care services. Health care is provided and managed by a Primary Care Provider/Case Manager (PCP/CM) that contracts to be a medical home for members on their panel. The level of medical home determines the care coordination payment the PCP receives. All other services are pay based on the OHCA current FFS payment methodology. PCP may also qualify for SoonerExcel incentive payments based on individual performance.. Physicians, nurse practitioners and physician assistants in primary care specialties can contract as PCP/CMs.
Quality Assurance
The OHCA is committed to ensuring that high quality health care is always available to its members. SoonerCare Choice providers agree to cooperate with external review organizations, internal reviews and other quality assurance efforts.
QQuuaalliittyy AAssssuurraannccee ((QQAA)) TToooollss
Quality assurance measures may include:
CAHPS Report Card
Annual telephone and mail surveys of SoonerCare Choice members are conducted by an external review organization, which measures health care satisfaction, including care provided by their PCP/CM.
After-Hours Surveys
Telephone surveys are conducted by the OHCA or one of its agents to ensure that PCP/CMs provide information concerning after-hours access to medical information or a medical professional.
Member Reports
Member calls to the SoonerCare Helpline for issues regarding quality of care or access to care needs are documented and forwarded to the OHCA for research and/or resolution.
On-Site Audits
On-site audits are conducted by OHCA Quality Assurance/Quality Improvement staff.
Encounter Data Reviews
Data reflecting medical care use rates, preventive care services and referral patterns are reviewed and analyzed. This information is Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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used in determining use patterns, referral patterns, rate setting and other reporting purposes.
Emergency Room Utilization Profiling
OHCA Quality Assurance/Quality Improvement staff perform quarterly analysis of PCP/CM office encounter claims submission versus emergency room claim submission. The results of these reports are forwarded to the PCP/CMs as well as SoonerCare Provider Services. The goal of this project is to reduce inappropriate use of emergency rooms.
SECTION A: COVERED MEMBERS
The Oklahoma Department of Human Services (OKDHS) determines the eligibility for all SoonerCare members. Members must meet financial, residency, disability status and other requirements before they can become eligible for SoonerCare.
SoonerCare Choice covers members who qualify for medical services through the Temporary Aid to Needy Families (TANF) program or those who qualify due to age or disability. Members may also include women who have been diagnosed with breast or cervical cancer under Oklahoma Cares, or children with disabilities who qualify under the Tax Equity and Fiscal Responsibility Act (TEFRA).
NNAATTIIVVEE AAMMEERRIICCAANNSS
Native Americans who are eligible for SoonerCare Choice must enroll with a Primary Care/Case Manager. They may choose a traditional SoonerCare Choice provider or enroll with an Indian Health Service, Tribal, or Urban Indian (I/T/U) clinic provider that participates in the program. All Native American members have the option to self-refer to any I/T/U facility for services that can be provided at these facilities.
SSOOOONNEERRCCAARREE CCHHOOIICCEE EEXXEEMMPPTT
Most members who are eligible for SoonerCare benefits will be enrolled in the SoonerCare Choice program. Individuals exempt from this mandate are eligible for Medicare and SoonerCare Traditional; enrolled in a waiver program, (examples being. Advantage or Home/Community waiver); residing in a long-term care center or institution; enrolled in a private Health Maintenance Organization (HMO); or a subsidized adoption. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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SECTION B: ACCESS TO CARE
SoonerCare Choice PCP/CMs are required to maintain access to primary and preventive care services in accordance to its contract. The following standards apply:
1. PCP/CMs must maintain 24 hour, seven day per week telephone coverage, which will either page an on-call medical professional or give alternate information to members concerning who they can contact to obtain medical advice. PCP/CMs are allowed to use the SoonerCare Patient Advice Line (PAL) for this purpose during the PAL‟s operating hours. These hours are 5:00 p.m. to 8:00 a.m. Monday through Friday. The PAL is available 24 hours per day on weekends and state of Oklahoma legal holidays. Please note, the PAL is not intended to replace a PCP/CMs obligation to assess and triage patients during normal business hours.
2. PCP/CMs must offer hours of operation that are no fewer than the hours of operation offered to commercial patients or SoonerCare Traditional members.
3. PCP/CMs must provide medical evaluation and treatment within 24 hours for urgent medical conditions. Generally, urgent care is for sudden illnesses or injuries where there is no immediate danger of death or permanent disability.
4. PCP/CMs must provide routine or non-urgent medical care within three weeks. Routine physicals or chronic conditions that require less frequent care may be excluded from this three-week period.
5. PCP/CMs that provide services to members 18 years old or younger are required to participate in the Vaccines for Children program through the Oklahoma State Department of Health (OSDH) and document immunization data in the Oklahoma State Immunization Information System (OSIIS) database.
o PCP/CMs can charge a co-payment to choice members.
Emergency Care
PCP/CMs are not required to provide emergency care either in its office or in an emergency room. PCP/CMs that do provide emergency care in the emergency room will be reimbursed based on current OHCA policy.
PCP/CMs should not refer members to an emergency room for non-emergeny services. Providers should interact with its assigned members to discourage inappropriate emergency room use. PCP/CMs should manage follow-up care from the emergency room, as needed. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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SECTION C: MEMBER ENROLLMENT/DISENROLLMENT
SSOOOONNEERRCCAARREE CCHHOOIICCEE EENNRROOLLLLMMEENNTT EEXXCCEEPPTTIIOONNSS
Exceptions to enrollment in SoonerCare Choice are individuals who are enrolled in an HMO; in a subsidized adoption; in a nursing home or special care center; in a home and community-based waiver; or eligible for Medicare and SoonerCare Traditional coverage.
SoonerCare member benefits start when DHS determines eligibility for SoonerCare Traditional and certifies the case. The effective date of SoonerCare Choice members‟ benefits depend on the certification date. Always check the Eligibility Verification System (EVS) either by calling the toll-free EVS line, through the swipe machine or on the Medicaid on the Web Secure Site.
NOTE: Medical care during the time a member is eligible for SoonerCare Traditional, but not yet effective in SoonerCare Choice, will be covered under the SoonerCare Traditional fee-for-service program.
Continuing eligibility for SoonerCare benefits must be recertified periodically. The recertification intervals vary according to the type of assistance members receive. SoonerCare members are notified in writing by DHS prior to the expiration of benefits.
Breaks in eligibility may mean a disruption in continuity of care. If the PCP/CM‟s capacity is limited in comparison to demand, the member may not be able to regain his or her place on that PCP/CM‟s panel.
Members may reenroll with a PCP/CM by calling the SoonerCare Helpline if they have a break in eligibility and are being recertified. Members who lose and regain eligibility within 365 days are assigned to their most recent PCP/CM, if the PCP/CM has available capacity and is within the PCP/CM‟s scope of practice.
Choosing a PCP/CM
The OHCA offers all members the opportunity to choose a PCP/CM from the provider directory. If a member does not choose a PCP/CM, the OHCA will contact the member to assist them in choosing a medical home. If a member seeks care prior to choosing a medical home the provider seeing the member will be the medical home.
Families with more than one eligible member are allowed to choose a different PCP/CM for each eligible member. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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Enrollment with a PCP/CM takes effect at the beginning of each month. Prior to the first day of each month, the OHCA provides the PCP/CM with a SoonerCare Choice eligibility listing of new enrollees and continuing members.
Capacity (Number of Members requested per PCP/CM)
The PCP/CM specifies the maximum number of members he or she is willing to accept. The maximum number is 2,500 members for each physician PCP/CM. The maximum capacity for physician assistants and nurse practitioners serving as PCP/CMs is 1,250. The PCP/CM must agree to a minimum panel of 50 members. The OHCA cannot guarantee the number of members a PCP/CM receives.
A PCP/CM may request a change in its capacity by submitting a written request to the Provider Enrollement division of the OHCA. If approved, the OHCA will implement the change on the first day of the month with sufficient notice.
If a PCP/CM requests a lower capacity - within program standards and it is approved by the OHCA - the reduction in members will come through members changing PCP/CMs or losing eligibility. Members will not be disenrolled to achieve a lower capacity.
Changing PCP/CMs
The OHCA or the SoonerCare Helpline may change a member from one PCP/CM to another PCP/CM for the following reasons: Member can request change without cause. When a PCP/CM terminates his or her participation in the SoonerCare Choice program.
Disenrollment At The Request of the PCP/CM
The OHCA may also change a member from the assigned PCP/CM to another PCP/CM for good cause and upon written request of the assigned PCP/CM. If the request is a good cause change, the OHCA will act upon the request within 30 days of receipt from the OHCA SoonerCare Choice division.
Good cause is defined as: Non-compliance with PCP/CM‟s direction. Abuse of PCP/CM and/or staff (includes disruptive behavior). Deterioration of PCP/CM- member relationship. Three no-show appointments.
The dismissal request and supporting documentation should be forwarded for processing to SoonerCare at 405-530-3228. Members may not be notified by the PCP/CM until approval for disenrollment is granted by the OHCA. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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Either party has the right to appeal the decision to the administrative law judge, pursuant to OAC 317:2-1-2 (the Authority‟s Grievance Procedure)
SECTION D: REFERRALS
SoonerCare Choice referrals are made on the basis of medical necessity as determined by the PCP; are required prior to receiving the referred service, except for retrospective referrals as deemed appropriate by the PCP/CM; and must have the correct provider referral number to ensure payment to the “referred to” provider (provider/referral numbers are site specific).
Referrals must be signed by the PCP/CM or a designee within the PCP/CM‟s office who is authorized to sign for the provider.
Some services may also require prior authorization. It is up to the “referred to” provider, or provider ordering services, to obtain prior authorization as needed. Prior authorization for services is obtained through the Medical Authorization Unit at OHCA.
SoonerCare Choice referrals must be made if the member requests a second opinion when surgery is recommended. Following the second opinion, any treatment received by the member is to be rendered by the PCP or through a referral made by the PCP/CM.
SoonerCare Choice referrals may be made to another PCP/CM for services equal to those of a specialist. Examples of this are, a family practitioner could refer to another family practitioner who performs a surgical procedure, or a general practitioner could refer to an internist who manages complicated diabetic patients.
SoonerCare Choice referrals may be made to a provider for ongoing treatment for time specified by the PCP/CM, but limited to 12 months. For the duration of the referral, the referred-to provider will not be required to receive further referrals to provide treatment for the specific illness indicated on the referral.
SoonerCare Choice referrals are not required for child physical/sexual abuse exams; services provided by a PCP/CM for members enrolled or assigned to the PCP/CM; emergency room care; obstetrical care; vision screenings for members younger than 21 years; Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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basic dental for members younger than 21 years (benefit is limited to emergency extractions for members older than 21 years); behavioral/mental health; family planning; inpatient professional services; routine laboratory and x-ray; or services provided to Native Americans in a tribal, IHS or Urban Indian Clinic facility.
Payment of Referred Services
Payment for referred services is subject to coverage limitations under the current SoonerCare reimbursement policies. Payment for referred services are limited to four specialty visits per month for adults older than 21 years. Visits to their PCP are excluded from this limitation. To ensure payment, PCP/CMs must refer only to SoonerCare providers that have an active SoonerCare Traditional contract.
Documenting the Medical File
Documentation in the medical record should include a copy of each referral to another health care provider and any additional referrals made by the referred-to provider when this information is known. An example might be ancillary services.
Documentation in the medical record should include a medical report from the referred-to provider. The referred to provider should report its findings to the referring PCP/CM within two weeks of the member‟s appointment. In the event a medical report is not received within a reasonable time, the PCP/CM should contact the referred-to health care provider to obtain this information.
Unauthorized Use of Provider Number
Unauthorized use of a SoonerCare Choice NPI number may result in official action to recover unauthorized reimbursements from the billing provider.
Referral Form and Instructions
In the SoonerCare Choice program, the PCP/CM is responsible for providing primary care and making specialty referrals. The PCP/CM completes the referral form, including the referral number. The PCP/CM‟s SoonerCare Choice NPI number serves as their referral number. The provider/referral number is site specific and must be for the site where the member is enrolled or assigned. The referral includes ancillary services rendered, or required, by the “referred to” specialist. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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With the PCP/CM‟s approval, a specialist may relay a copy of the original referral to other specialists with instructions considered necessary for proper member treatment. Payment is subject to the current SoonerCare reimbursement policies.
The provider mails the original of the completed form to the specialist, or “referred to” provider. A copy of the form is retained in the patient‟s medical record.
When a claim is submitted by a “referred to” provider, the referral number must be entered in box 17a of the 1500 claim form, or box 30 of the UB-04 hospital claim form. A copy of the referral should not be attached to the claim. If the referral number is not on the claim form, payment will be denied unless for self-referred services.
Referral forms can be accessed and printed from the Forms page on the OHCA Web site at www.okhca.org.
SECTION E: EPSDT
Early and Periodic Screening Diagnosis and Treatment (EPSDT) is a federally mandated program and one of the highest priorities of the SoonerCare Choice program. EPSDT is designed to provide a comprehensive program of preventive screening examinations, dental, vision, hearing and immunization services to SoonerCare Choice members age 20 or younger.
Schedule of EPSDT Services
As a minimum, the following schedule for EPSDT screening is required: Six visits during the first year of life. Two visits in the second year of life. One visit yearly for ages two through five. One visit every other year for ages six through 20. Metabolic lead screen at ages one and two; or six years old if not done by age 2. This is mandatory.
Additional Requirements
The OHCA requires contractors to: Conduct and document follow-up appointments with all members younger than 21 years old who miss appointments. Administer outreach, including telephone calls or printed notification mailed to a member when a health care screen is indicated or missed. This ensures that all members who are age 20 or younger are current. Educate families of members age 20 or younger about the importance of early periodic screening, diagnosis and treatment. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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EPSDT Bonus Payment
The OHCA offers bonuses paid to PCP/CMs that demonstrate a specified screening rate.
To qualify for the EPSDT bonus, verifiable encounter claim data must be submitted in a timely manner as set forth in the SoonerCare Choice contract (Section 6.2 for year 2007) and for any following contract addendums.
The OHCA may conduct onsite chart audits.
See the Reimbursement section below for further bonus payment details.
SECTION F: REPORTING REQUIREMENTS
Data, information and reports collected or prepared by the PCP/CMs in the course of performing its duties and obligations as a PCP/CM are owned by the state of Oklahoma. The OHCA and other appropriate entities reserve the right to examine this information upon request. This information includes medical and financial records, accounting practices, and other items relevant to the provider‟s contract.
The PCP/CM is required to report to the OHCA in writing and within a timely manner any changes to its SoonerCare Choice contract. The report must include demographic, financial and group composition information as reported in their contract.
Claims submitted by the PCP/CM should be submitted in the same manner and on the same claim forms used to submit claims for SoonerCare Traditional members. Encounter Claims must be submitted within 60 days from the date of services. Denied claims must be corrected and resubmitted within 60 days of adjudication.
SECTION G: REIMBURSEMENT
CCHHAANNGGEE TTOO CCAARREE CCOOOORRDDIINNAATTIIOONN
SoonerCare Choice PCP/CMs are paid a care coordination payment for each member enrolled with them on a monthly basis.
Care Coordination payments vary according to the type of members the PCP services and their level of medical home status.
Care Coordination payments are made by the 10th working day of each month for all eligible members enrolled with the PCP/CM on the first of each month. A single monthly payment is generated and accompanies the Care Coordination Listing or is deposited directly. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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CCLLAAIIMMSS
PCP/CMs are required to file a claim with the OHCA each time a service is provided to a member. Claims filed will be paid subject to the current SoonerCare Traditional fee schedule and reimbursement policies.
Claims are to be submitted on a 1500 claim form within 60 days of the date the service was provided.
TTAANNFF SSTTOOPP LLOOSSSS
To limit risk to PCP/CMs, a threshold of $1,800 per year in capitated services ($450 per quarter) is established by the stop-loss for members eligible through TANF. This is based on the SoonerCare Traditional fee schedule allowables; not gross charges.
IIMMMMUUNNIIZZAATTIIOONN IINNCCEENNTTIIVVEE PPAAYYMMEENNTT
Immunization Incentive Payments are available when the PCP/CM provides written notice that it has administered the 4th dose of DPT/DTAP to a member before the member‟s second birthday.
SECTION H: PROVIDER RESOURCES
SoonerCare Choice PPRROOVVIIDDEERR RREEPPRREESSEENNTTAATTIIVVEESS
1. SoonerCare PCP/CMs and all other SoonerCare providers have provider representatives to answer questions or policy issues, research complex claim issues and provide onsite training and support. These provider representatives can be reached by calling toll free at 877-823-4529, option 2. Provider representatives will be available to assist you with questions, claim resolution or directing you to your on-site provider representative.
EDS Field Consultants
EDS field consultants make onsite visits to assist providers with billing questions and train providers to summit online claims through the OHCA Web site. The field consultants conduct bi-monthly training sessions along with the spring and fall workshops. Providers can locate their EDS field consultant by visiting the OHCA Web site at www.okhca.org. Once there
1. click on the Provider link in the center of the page;
2. click on the Training link under the Providers header on the left side of the next page; and
3. click on the EDS Field Consultants link on the right of the next page where you will find your field consultant.
Patient Advice Line
The Patient Advice Line is a service available only to SoonerCare Choice members. Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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AAuuddiioo TTaappee LLiibbrraarryy
The Member Handbook lists a few of the more than 1,100 recorded topics accessible on the Patient Advice Line.
SSoooonneerrCCaarree CChhooiiccee PPaattiieenntt AAddvviiccee LLiinnee is accessible Monday through Friday, 5 p.m. to 8 a.m., 24 hours on weekends and state of Oklahoma legal holidays; offers triage services to members based on nationally recognized triage protocols; and is staffed by registered nurses.
AAfftteerr HHoouurrss
Your after hours recording may instruct your SoonerCare Choice members to call the Patient Advice Line; however, the Advice Line serves as a supportive program and is not a replacement for after-hours provider coverage.
The Patient Advice Line offers assistance in determining if the caller has an emergency or urgent care need and educates the caller on home care.
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If the Patient Advice Line directs the member to seek emergency room care, your office and the SoonerCare Division of the OHCA will receive fax notifications the next business day.
SoonerCare Choice Patient Advice Line
Toll-free at 800-530-3002
Hearing impaired, dial SBC Relay Oklahoma at 800-722-0353 (TDD/TTY)
Translation Services
The SoonerCare Helpline offers translation services 24 hours a day, seven days a week. If you cannot communicate with the member because of language, call the SoonerCare Helpline at 1-866-872-0807 and enter state code 53510.
The Patient Advice Line (PAL) is available for translation services from 5 p.m. to 8 a.m. weekdays and 24 hours per day on weekends and state holidays. Please call PAL at 800-530-3002 for assistance during these times. The PAL contract with AT&T‟s translator service accommodates more than 140 languages and dialects. Physicians with a SoonerCare Choice member who does not speak English can use this service during the member‟s office visit. They can also connect with this service any time a non-English speaking member calls.
CCAARREE MMAANNAAGGEEMMEENNTT The Care Management Department is comprised of registered nurses and licensed practical nurses. These medical professionals Chapter 3: SoonerCare Choice The OHCA Provider Billing And Procedure Manual
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assist in facilitating medical services for SoonerCare members with complex medical conditions.
CCaarree MMaannaaggeemmeenntt SSeerrvviicceess help members access care and services; assist providers with coordination of discharge planning; resolve issues and concerns with providers as related to medical care; help get approvals for medicines and medical services; provide patient education to identified groups; assist with coordinating community support and social service systems; and offer out-of-state referrals if no comparable in-state services are offered or in cases of urgent care needs.
CCoommpplleexx mmeeddiiccaall ccoonnddiittiioonnss iinncclluuddee high risk OB cases; transplant cases; catastrophic illness or injury; women enrolled in the Breast and Cervical Cancer (BCC) program; and children receiving in-home Private Duty Nursing services (includes periodic home visits to evaluate & certify medically necessary services).
QQuuaalliittyy AAssssuurraannccee oovveerrsseeeess iissssuueess wwiitthh Care Management Referral forms; high service utilization; medical regimen noncompliance; inappropriate ER visits; multiple providers/pharmacies; scheduled medication requests; refusing alternate treatments/prescriptions; refusing pain management referrals; and drug seeking behaviors.
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Provider Billing And Procedure Provider Billing And Procedure Manual Chapter 4: Member Eligibility Verifications The OHCA Provider Billing And Procedure Manual
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INTRODUCTION
The OHCA contracts with the Oklahoma Department of Human Services (OKDHS) to determine Medicaid SoonerCare eligibility using federal and state eligibility criteria. Most Medicaid SoonerCare criteria related to income levels are determined by the federal poverty guidelines established by the U.S. Department of Heath and Human Services. Visit the Oklahoma Department of Human Service Web site at http://www.okdhs.org/programsandservices/health/ to obtain additional information on member enrollment in medical services.
SECTION A: MEMBER ID CARD
Medicaid SoonerCare members receive a permanent plastic identification card. The Medicaid Medical ID card is a white card with brown and green graphics. The card can be used for accessing the EVS system or a commercial swipe machine system to verify a member‟s eligibility before providing a Medicaid SoonerCare service. Shown below is an example of the medical ID card.
Members are encouraged to keep their card with them at all times; however, this card is not required to be provided by the member to receive services. Eligibility can be verified by using the member‟s ID number from their card, member‟s Social Security number with member‟s date of birth, member‟s first and last name along with date of birth or the member‟s DHS case number; leaving off the 2-digit person code. It‟s the provider‟s responsibility to verify the member‟s eligibility on a per visit basis to ensure the member‟s continued eligibility for Medicaid SoonerCare coverage. Failure to verify eligibility prior to rendering services could result in a delay or denial of payment.
SECTION B: OPTIONS TO VERIFY MEMBER ELIGIBILITY
As an Oklahoma Medicaid SoonerCare provider, it is imperative that the member‟s eligibility is verified before providing any services. Providers can check a member‟s eligibility using one of Chapter 4: Member Eligibility Verifications The OHCA Provider Billing And Procedure Manual
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four sources: Eligibility Verification System (EVS), the secure Web site, swipe machines or Electronic Data Interchange (EDI). The purpose of the ID card is to give sufficient information to verify eligibility of the member. The card by itself is not a guarantee of eligibility. Providers need a Personal Identification Number (PIN) to access the Oklahoma Medicaid secure Web site and the EVS. If a provider forgets their PIN, they can obtain it by calling the Security Help Desk toll free at 800-522-0114 or within the Oklahoma City metro area at 405-522-6205 and selecting options 2 then 1.
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The EVS provides a national toll-free telephone number to help providers obtain member eligibility, third party liability (TPL), warrant, prior authorization and claim inquiry information. Providers can also request prior authorization and eligibility fax backs. There are two ways to use the EVS system. A caller may use the touch-tone system or the automated voice response (AVR)/speech recognition system. A PIN is required to access member eligibility information. The four-digit PIN expires every six months. Providers may reset their PIN by staying on the phone and following the prompts.
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The touch-tone system allows a caller to go through the call by using the telephone‟s number pad. The caller‟s telephone must have touch-tone capability, as rotary style phones will not work on the touch-tone system.
AAllpphhaa CCoonnvveerrssiioonn
Entering the provider‟s SoonerCare ID number can access eligibility information. This will be a nine-digit number and the one alpha character location code that was assigned by the OHCA. A location conversion code has been established for the alphabet to be used in conjunction with the EVS. The codes are patterned to coincide with the location of numbers and letters on a telephone keypad. For example, the letter A converts to *21. The number 21 represents the second button and the first letter on the second button of the telephone keypad. The letter R converts to *72, representing the seventh button, third letter. See the alpha conversion chart below. Chapter 4: Member Eligibility Verifications The OHCA Provider Billing And Procedure Manual
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Alpha Conversion Chart for EVS
AAVVRR//SSppeeeecchh RReeccooggnniittiioonn
Providers without a touch-tone phone can access information using the AVR. The AVR system allows a caller to use a speech application. By speaking into the phone, a caller is able to use the system to get all the information they need. The system is available seven days a week from 5 a.m. to 1 a.m.
Nationwide Toll Free: 800-767-3949
Oklahoma City Metro Area: 405-840-0650
Secure Site Eligibility Verification
Providers have the ability to verify member eligibility through the Secure Web site. They do this by logging into the secure site and clicking on the Eligibility tab. The member may use his or her ID number, Social Security number with date of birth, the member‟s first and last name along with date of birth or the DHS case number to check eligibility. This must be combined with the “from” and “to” dates of service. Arrow buttons next to the date-of-service fields activate a calendar pop-up feature to aid in selecting dates. The resulting data appear below the search criteria. When searching eligibility on the secure Web site, the Web site will display a verification number and a status of A or N. The verification number and the status do not reflect the member‟s eligibility. The member‟s eligibility information is listed under the section titled “Eligibility”. Checking eligibility on the secure Web site will also give Third Party Liability (TPL) and Medicare coverage information.
Swipe Card
This device, similar to a credit card machine, hooks into a phone jack. The provider swipes the Medicaid SoonerCare ID card through the reader, which reads the magnetic strip. The eligibility information is displayed on the screen or printed on a paper slip. Providers interested in the swipe card option can contact a third party vendor for details.
Electronic Data Interchange (EDI)
EDI is a way for providers to check eligibility on a larger scale than the previous options. Providers purchase third party, HIPAA compliant software used to send a 270 transaction with their search
A=*21
F=*33
K=*52
P=*71
U=*82
Z=*12
B=*22
G=*41
L=*53
Q=*11
V=*83
C=*23
H=*42
M=*61
R=*72
W=*91
D=*31
I=*43
N=*62
S=*73
X=*93
E=*32
J=*51
O=*63
T=*81
Y=*93
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criteria and receive a 271 response, which provides eligibility information. A 271 will give providers information on the different programs the member has as well as any TPL or Medicare information.
Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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INTRODUCTION
The OHCA secure site is one of the most exciting features of the Oklahoma Medicaid Management Information System (MMIS). The efficiency and convenience of the Internet remote access server (RAS) gives all Oklahoma SoonerCare providers fast access to member and provider specific information. Any SoonerCare provider can access the Web/RAS with its Provider ID and an OHCA-generated personal identification number (PIN). Once the provider has established a free account, they can create new clerks and grant each clerk role-specific access. The Web/RAS is always available.
IIMMPPOORRTTAANNTT WWEEBB SSIITTEE NNOOTTEESS:: User names and passwords are case sensitive. All dates should be entered in MMDDYY format. Dollars and cents should be separated by a decimal. Line totals will not be calculated automatically; the user must multiply the units by the unit rate to ensure the correct total billed amount. Do not populate the TPL amount unless another payer has paid a specific amount toward the claim. Decimals should not be used when entering diagnosis codes.
SECTION A: ACCESSING THE SECURE WEB SITE
The secure Web site can be reached through the public Internet. All that is required are Microsoft Internet Explorer browser version 6.0 or higher 128 bit encryption; and customized security settings to access information across domains.
Windows 98 users will need Microsoft updates. For more information on required updates, please contact EDS Internet Help Desk.
GGEETTTTIINNGG TTOO TTHHEE SSEECCUURREE WWEEBB SSIITTEE
1. Go to www.okhca.org.
2. Under the Provider header in the center of the screen (see Screen Sample 5.1), click on the “Secure Site” link to get to the OHCA secure site. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.1
NOTE: On the OHCA Web site, providers have complete access to all the latest Oklahoma Medicaid related information and updates.
LLOOGG OONN PPAAGGEE
The Log On page serves as the access point for all Internet users. Users will begin account initialization and log on from this page, once accounts are established.
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Screen Sample 5.2
AACCCCOOUUNNTT IINNIITTIIAALLIIZZAATTIIOONN
A user will go through an initialization process the first time they log on to the secure site (see Screen Sample 5.2). This will differ depending on the security level of the user.
LLOOGGGGIINNGG OONN
1. Enter the secret ID specific to your role:
Providers - Under „First Time Here,‟ enter the Provider ID number in the Log On ID field. This does not include the service location alpha character. (i.e. 123456789).
Billing Agents – Under „First Time Here‟ enter the submitter ID given to you by EDI in the Log On ID field.
Clerks – Under „Already a Member‟ enter the name generated by your provider or billing agent. Enter the password in the Password field and skip Step 2.
2. Enter the 9-character PIN in the PIN field.
3. Click the Log On button at the bottom of the page.
4. After clicking logon a popup window will appear called the OHCA usage security agreement statement. There will be I Agree and I Disagree options at the bottom. Clicking I Agree will take you to the Account Maintenance Screen. Clicking I Disagree will bring you back to the logon page.
NOTE: This statement will not appear if a popup blocker is on. It will go to the account maintenance screen, which will ask you to save. All popup blockers must be turned off in order to see the popup screen with the Save button. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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4. Enter a user name in the User Name field. The user name must start with a letter of the alphabet and be six to 12 characters.
5. Enter a password in the New Password field. The password must begin with a letter of the alphabet, be six to eight characters and contain no fewer than two numeric characters.
6. Confirm the password by retyping it into the Confirm Password field.
7. Enter a contact name in the Contact Name field. Providers need to enter the clerk‟s full name. Clerks are not authorized to do this.
8. Enter an e-mail address in the E-mail field.
9. Enter phone number in the Phone Number field.
10. Enter two self-authentication questions and answers. Clerks only.
11. Click on the Submit button.
If all data was entered correctly, a box will pop up telling you that your data have been successfully saved.
12. Click the OK button.
13. Click on the Save button.
14. Click the Log Out button.
After setting up your user name and password, future login attempts are done at „Already a member?‟ by entering the user name in the User Name field and entering the password in the Password field.
TTYYPPEESS OOFF WWEEBB UUSSEERRSS
LLeevveell 11 ((PPrroovviiddeerrss))
Providers will receive a letter by mail containing the provider‟s access PIN. This PIN, used in conjunction with the Provider ID, will grant the provider initial access to the secure Web site. Only providers with an active SoonerCare contract will receive a PIN letter. Separate PIN letters will be mailed to each location. It is recommended that providers initialize their account and immediately create Level 2 users (clerks) that will be used to operate the Internet application on a daily basis. Operating daily under the Level 1 (Provider) master user poses certain security risks and should only be used when managing the account.
LLeevveell 11AA ((BBiilllliinngg AAggeennttss))
Billing agents are given log-on credentials directly from the OHCA. When the users initialize their accounts, they will be forced to establish a password and contact information. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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LLeevveell 22 ((CClleerrkkss))
The provider or billing agent that created the clerk will give clerks log-on credentials. Users will be required to establish a password, contact information, and self-authentication questions and answers upon initializing their accounts.
DDrruugg MMaannuuffaaccttuurreerrss
Drug manufacturers must request online access. A PIN letter will be mailed to the requesting company once the user requests access and the request is approved. Users will establish a password, contact information, and self-authentication questions and answers upon initializing their accounts.
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Other users include: The Oklahoma Department of Human Services (OKDHS) and any other agency that intends to access the secure Web site via the public Internet. Internet users of this type will be created by the OHCA administration, and credentials will be given to them. Users will establish a password, contact information and self-authentication questions and answers when initializing their accounts.
FFOORRGGOOTT PPAASSSSWWOORRDD
Users who forget their passwords may still gain access to the secure Web site through the self-authentication process. The self-authentication process requires the user to change his or her password.
UUsseerrss WWhhoo FFoorrggeett
Users who forget their password must provide his or her PIN and Provider ID. Valid data will take users to the account maintenance page where they will create a new password. They will go to the secure Web site after the new password is set.
BBiilllliinngg AAggeennttss oorr CClleerrkkss TThhaatt FFoorrggeett
Billing agents or clerks that forget their passwords can click on the Tab, “Forgot Password?” and answer the two secret questions they set up the first time they logged on. They are then taken to their account maintenance screen to change their password.
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SECTION B: WEB FEATURES
The OHCA secure site has many features to help providers with everything related to Medicaid billing. This section will cover several OHCA secure site features.
GGLLOOBBAALL MMEESSSSAAGGEESS
This is the first page the user will see after logging on. It will have global messages from the OHCA that can be directed to an individual provider, a specific provider type, or to the entire provider community.
After reading each message, click on the Read box. This will move the message to the Mailbox for future reference until it expires.
After reading all messages, click on the Next button.
MMAAIINN PPAAGGEE
The Main page is the user‟s home page. The Main page shows the User ID and the taxonomy number, provides information about the direction of remittance advices and contains shortcut links to all areas of the Web site.
DDrruugg MMaannuuffaaccttuurreerr MMaaiinn
This Main page is only available to drug manufacturer users. It contains a brief description of the features available to drug manufacturers, a phone number to call for questions and a link to the download page.
SSwwiittcchh PPrroovviiddeerr
The Switch Provider page is only available to clerks and billing agents. This feature allows the user to select the provider he or she wishes to access. The provider must grant access to the billing agent or other user through the Account Maintenance page before this functionality is available. To switch to a different provider, click the hyperlink of the desired provider ID found on the Main page. The “Next” button will take the user back to the Main page.
CCLLAAIIMMSS PPAAGGEE
The Claims Page facilitates the communication of claim data between the OHCA and the provider community.
Providers without access to HIPAA compliant Practice Management software, a clearinghouse or a virtual access network (VAN) still have the ability to submit claims electronically. Direct data entry (DDE) enables the provider to submit individual claim information electronically to OHCA/EDS without the constraints of having to submit the data in HIPAA compliant format. DDE claim pages are available on the OHCA secure Web site for all claim types (i.e. professional, institutional, dental and pharmacy). Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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These pages contain separate box/fields where claim data must be populated. As with paper claim forms, box/field population requirements depend on the billing situation. However, if a provider attempts to submit a claim via the DDE page and has not populated all required fields, the system will prompt a pop-up box stating which required fields are unpopulated.
Direct Data Entry processes can only be performed one claim at a time.
CCllaaiimm IInnqquuiirryy
Users may inquire about claims already submitted to the OHCA/EDS using client ID, patient account number, internal control number (ICN), status, dates of service and warrant dates. A results box from the search will appear below the search criteria in the form of a summary list. Twenty results will appear at a time with navigation links below the box to view the next or previous list of results from the query. Each summary result item is hyperlinked to the claim detail page in the ICN and hyperlinked to the Client Eligibility page in the Client ID.
PPeerrffoorrmmiinngg aa CCllaaiimm IInnqquuiirryy::
1. Click on the Claim Inquiry link, or move mouse pointer over the Claims tab, highlight Claim Inquiry and click on it.
2. If known, the client ID number can be entered in the Client ID field.
3. The Claim Status field can be set to, „Any Status,‟ „Denied,‟ „Paid,‟ „Suspended,‟ or „Resubmit‟.
4. If the patient account number is known, it can be entered into the Patient Acct. # field.
5. Choose a date type by selecting either the „Date of Service‟ or „Warrant Date‟ Date Type radio buttons.
6. If known, the ICN can be entered in the ICN field.
7. The from date of service can be entered into the From Date field, and the thru date of service can be entered into the Thru Date field.
8. Click on the Search button.
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CCllaaiimm SSuubbmmiissssiioonn
Providers need to confirm that they are logged in under the correct provider number location before starting claim submission.
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1. Pull up „Denied‟ claims (from the Claim Status field), along with any other search criteria.
2. Click on the ICN link of the claim that needs correction.
3. Change the information in the field containing the incorrect data and click on the Re-Submit button.
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1. Pull up „Paid‟ claims (from the Claim Status field), and any other search criteria.
2. Click on the ICN link of the claim that needs to be voided.
3. Click on the Void button. This will create an account receivable for the amount previously paid, which will be deducted from a future warrant.
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1. Pull up „Paid‟ claims (from the Claim Status field), along with any other search criteria.
2. Click on the ICN link of the claim that needs to be copied.
3. Click on the Copy Claim button. Make any changes to Client ID number, procedure codes, date of service or any other fields you need changed to make a new claim.
4. Click the Resubmit button.Institutional Claim Submission From this page, users may submit, resubmit, adjust and void institutional claims. Claims are sent as HIPAA compliant .xml format. The page includes field edits for data format and required fields. Claim adjudication response is immediate and EOBs display in real time below the claim form in the claim status box.
Professional Claim Submission
From this page users may submit, resubmit, adjust, and void professional claims. Claims are sent as HIPAA compliant .xml format. The page includes field edits for data format and required fields. Claim adjudication response is immediate and EOBs display real time below the claim form in the claim status box.
Dental Claim Submission
From this page, users may submit, resubmit, adjust and void dental claims. Claims are sent as HIPAA compliant .xml format. The page includes field edits for data format and required fields. Claim adjudication response is immediate and EOBs display in real time below the claim form in the claim status box. Pharmacy Claim Submission From this page, users may submit, resubmit, adjust and void pharmacy claims. Claims are sent as HIPAA compliant .xml format. The page includes field edits for data format and required fields. Claim adjudication response is immediate and EOBs display in real time below the claim form in the claim status box. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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The purpose of the Eligibility page is to verify eligibility of SoonerCare members. To run a query, a valid client ID, Social Security number and date of birth, name or case number lookup are needed. This must be combined with the “from” and “to” dates of service. Resulting data will appear below the search criteria. Calendar buttons next to the dates of service fields will activate a calendar pop-up feature to aid date selection.
Pricing Page
The Pricing page allows users to inquire on pricing information for procedures and drugs through the Internet. Selecting the radio button for Procedure or Drug will change the available options for searching. A drop-down menu is available for the user to select the associated benefit package and all resulting data will be based on that selection. The search results summary will appear in a list below the criteria. This summary will be hyperlinked to a detail page.
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The detail page for procedure pricing will display all vital procedural components. A field will only appear if data are present for that procedure. Displayed data may include procedure code; allowed amount; PA requirement; maximum units; gender requirement; attachment requirement; lifetime limitation; diagnosis; restriction; or specialty restriction.
DDrruugg PPrriicciinngg
The detail page for drug pricing will display all vital data regarding the drug. A field will only appear if data are present for that drug. Data displayed are NDC Code; EAC; MAC; PA Requirement; maximum units; maximum days supply; age restriction; gender requirement. measurement unit for pharmacy claims; and measurement unit for non-phamacy claims.
PPRRIIOORR AAUUTTHHOORRIIZZAATTIIOONN PPAAGGEE
The prior authorization (PA) windows allow the user to submit new PA requests, to inquire about pending prior authorization requests and to inquire/copy notices. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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The PA Submission page allows users to request a prior authorization.
The header section requests information about the patient and provider. Enter appropriate information in boxes. Below the header section is a large summary box that alternates between line items, notes and attachments, depending on the user selection to the left of the summary box. Line item boxes are used to enter procedure-code-related details. The Attachments box is used to enter ACNs to facilitate matching with attachments sent to the OHCA. The Notes box is used as a free form text box for additional information from the provider to OHCA prior auth analysts.
The next section consists of detail boxes. The user enters the appropriate information in the detail boxes and clicks the Add button to move the information to the summary box, which clears the detail box or boxes for additional entries. When complete, click the Submit button.
If required information is missing, the user will be prompted to enter that information and click the Submit button again.
PPrriioorr AAuutthhoorriizzaattiioonn IInnqquuiirryy
1. Click on the Prior Authorization link, then click on the Status Inquiry link or move the mouse pointer over the Prior Auth tab, and highlight and click on Inquiry.
2. If you have the PA number, enter it in the PA Number field.
3. If you don‟t have the PA number, you may search for it by entering the client ID number in the Client ID field and enter the assignment code in the Assignment Code field by clicking on the down arrow, highlighting the appropriate choice and clicking on it.
4. You can also search by entering a drug code in the NDC field and/or by entering a date in the Start Date field by typing it in or by clicking on the down arrow to pull up a calendar.
5. Click on the Search button.
A start date can be added to increase the filter. Search results are displayed in a list box of 20 results at a time. If more results exist, they may be viewed by using the Prev. and Next links below the list box. Selecting a result summary line will open the PA detail window.
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The PA Summary page appears when a user searches a PA using the PA Inquiry page. The header section outlines information about the patient and provider. Below the header section is a section that alternates between line items and notes, depending on the user‟s selection to the left of the summary box. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Line item boxes are used to review procedure-code-related details and status. The Reason Code section and I.A.C. section also relates to each line item highlighted in the Line Item summary box.
The Notes box is used to review notes entered to an OHCA PA analyst.
PPrriioorr AAuutthhoorriizzaattiioonn NNoottiicceess
Go to the Prior Authorization drop-down menu, click on the Notice link and search by one of the following: Client ID or member name to access recent PA notices submitted under your provider number for that member. PA Number of a specific PA. This will bring up only the notices related to that number. Click the Search button and you may view all the PA notices under your provider number. Click on Count Summary to access the Notice image number. This will bring up the PA notice letter, which can be printed.
On each column, the provider can click on the up or down arrow that will allow them to sort ascending or descending order.
AAddddiittiioonnaall ttiiddbbiittss ffoorr ssuucccceessssffuull uussee When searching by either a specific PA number, client ID, or member name the Date Span fields are auto populated with a 60-day span. The From date counts back 60 days from the Through date. The Through date is the day the research is being conducted. The Web program holds a 60-day rolling submission history. For example, if the PA request was entered into the system on 01/01/06, it will be available for online viewing until 03/02/06. When logged on to a Group Provider number, the system will bring up PA information for every provider in that group.
On the Main page of the secure Web site, a message has been added that will tell you the number of unread PA notices under this provider log on.
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Trade Files pages are available to providers to facilitate file transfers between the provider community, drug manufacturers, other involved agencies, and the OHCA.
FFiillee UUppllooaadd
The File Upload page allows the user to select a file from a local hard drive and upload it to the OHCA. Users of this feature include Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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providers that wish to upload batch claim submissions and managed care providers that wish to upload PCP information. Batch upload is an Internet submission option that is available to providers who wish to submit large claim batches or inquiries. To use the Batch Upload option, providers must use HIPAA compliant software or clearinghouse/VANs that can submit required data in HIPAA compliant ANSI X12 Addenda format. Once the provider has ensured the batch claim data have been converted into the corresponding HIPAA compliant format and have successfully completed authorization testing with the EDS-EDI team, they then have the ability to upload an entire batch file/transaction into the Oklahoma Medicaid Management Information System (OKMMIS).
If users wish to upload a batch, they must go to the Trade Files page. Pointing at the Trade Files option and clicking on the Upload feature will take them to the Upload page (Screen Sample 5.3).
Screen Sample 5.3
From this page, the user will need to click on the Browse button to locate the file they wish to upload. The user then has the ability to change the file name in the Save as Filename box. Next, click on the drop-down arrow next to the Transaction Type box and pick the appropriate type that corresponds with their transaction. Once all information is complete, the user clicks on the Upload button. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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When the file uploads, the user will see the page stating the upload was successful and the Transaction ID assigned to it (Screen Sample 5.4).
Screen Sample 5.4
The Upload process is now complete for the user. This process must be repeated for all files uploaded via the Web/RAS.
FFiillee DDoowwnnllooaadd
The File Download page allows the user to select a file from the provider secured Internet site and download it to their system. The available files will be listed as hyperlinked file names. The download process begins when the link is clicked. A compressed or “zipped” file will download to the user‟s system. Compression software is required to open the file. Users of this feature include providers that wish to download batch claims or response files, drug manufacturers that wish to download their invoices and managed care providers that wish to download managed care roster information.
To download a file (i.e., an 835 Remittance Advice), click on the Download feature. The Download page will open. All files that were created for the specific user/provider will be found on this page (Screen Sample 5.5). Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.5
To download one of the listed files, click on the file name. It will either begin to download or a dialog box will open, depending on your browser settings. Download the file according to your usual protocol. The file will automatically download with the default name of “getfile.zip” or “getfile.z,” depending again on your browser.
NOTE: If you are downloading multiple files, you will want to extract the file and rename it before downloading another file to avoid replacing the original “getfile” with your new “getfile.”
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The Account Maintenance page is the first page that users will see when they initialize an account. This page is designed to establish the security credentials for users and clerks, and allows users to update and maintain user account data.
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After users access the Web site for the first time and initialize their account, they are brought to this page. Here users will establish their user names, passwords, contact names and phone numbers. The e-mail field is optional. The security level, status and last logged on dates are maintained by the application and are not updateable by Level I users.
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BBiilllliinngg AAggeenntt oorr CClleerrkk
Adding a billing agent or clerk is done by clicking the Create New Clerk button. A separate box will appear where the new clerk‟s information will be entered.
1. In the User Name field, create a generic name (i.e. CLK12345).
2. In the Contact Name field, enter a valid contact name.
3. In the Password field, enter a generic password (i.e. CLK12345). NOTE: The clerk must replace the generic user name and password with desired selections when they logon the first time.
4. To add all roles, click on the Add All Roles button and skip to Step 7.
5. To add only specific roles, select the role(s) from the list on the right of the screen. To select more than one role, hold the CTRL key while selecting roles.
6. Click on the Grant Role button after selecting the desired role(s). The selected roles appear in the list on the left.
7. To delete a role from the list, highlight the role in the list on the left and click the Cancel Role button. Select the Cancel button to abort the clerk creation process.
8. Click on the Create Clerk button and then the Save button to complete the assignment.
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After a clerk or agent is created, he or she will automatically have access to the provider account under which he or she was created. In order for the clerk or agent to access other providers‟ accounts, access must be granted.
1. Go to the account maintenance section by selecting the Account tab at the top of the page.
2. Key the user name of the clerk or agent to be granted access in the User Name field within the Provider Associations area.
3. To designate the user to receive RAs, rosters, and/or capitation summaries, place a check in the appropriate box(es).
4. Click on the Grant Access To button.
a. Click on the Edit Clerk Roles button to add roles for the existing clerk.
b. To add all roles, press the Add All Roles button.
5. To add only specific roles, select the role(s) from the list on the right of the screen (to select more than one role, hold the CTRL key while selecting roles). Click on the Grant Role button. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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6. Click on the Update Clerk button when all selections are made.
7. Click the Save button when back on the Account page.
NOTE: This process must be followed for each provider account to which the clerk or agent needs access.
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When a billing agent or clerk no longer needs access to your provider account, you must revoke his or her account privileges.
1. Log in as the provider and click on the Account tab at the top.
2. Highlight the user name from the list in the box and click on the Revoke Permissions button.
3. A box will appear asking if this clerk should be revoked access to the account. Select the OK button to complete the process or select Cancel to deny the revocation.
4. After selecting OK, click the Save button.
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The Account Maintenance page for Level IA users operates the same as the above Level I in all aspects, except that the Level IA user will be forced to establish self-authentication questions and answers when the account is initialized. These questions and answers may be updated at any time.
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The Account Maintenance page for Level II users operates the same as the above Level IA in all aspects – except that the Level II user does not have the ability to create, grant access to, or revoke permissions of other Level II users.
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The Mailbox page contains messages from the OHCA directed specifically to certain groups, such as specialties. After successfully accessing the secure Web site, the Mailbox page displays first. The Mailbox will always display any active messages not checked as read. Next to each message is a Read check box. When this is selected, the message will no longer appear at log on. However, the message will still be available by clicking the Mailbox link from the menu and remains in the Mailbox until it expires. The administrator who sends the message determines the expiration date. Below the messages is the Next button. Selecting this button will take the user to the Main page.
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The Help pages for the secure Web site are dynamic in that the help text that displays is unique to the page that the user is viewing. Help pages also include a button titled, Ask Tech Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Support. This button opens a page that has a text box for asking a question. When you click Send on this page, the text you typed and the .xml file from the Web page you are viewing is sent to a call support specialist for review.
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Clicking the Log Off Tab ends your current session on the secure site and directs you to the Log Off page. The Log Off page displays the non-secure menu options. Clicking the Log Back On button will take you to the Log On page.
SECTION C: REMOTE ACCESS SERVER (RAS)
you may use the Remote Access Server (RAS) to submit claims through an existing dial-up connection. The RAS lets providers use all options of OHCA‟s secure Web site without an Internet service provider. Basic requirements to log on the RAS are an analog phone line, a modem and Internet Explorer 5.0 (or higher).
Screen Sample 5.6
The first step in accessing the RAS is to create a new connection for the Oklahoma Medicaid Remote Access Server (see Screen Sample 5.6). To prompt the Network Connection Wizard
1. click on the Start button on the main toolbar;
2. drag mouse up to Programs;
3. drag mouse over to Accessories;
4. drag mouse over to Communications; and
5. drag mouse over to Network and Dial-up Connections and click on it. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.7
Once you have the Folder opened for Network and Dial-up Connections (see Screen Sample 5.7), click on the “Make New Connection” icon to start the Network Connection Wizard.
Screen Sample 5.8
Once the Network Connection Wizard has started (see Screen Sample 5.8), this box appears and guides the user through the network creation process. The first step in the setup process is to click Next. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.9
In the “Network Connection Type” box, (see Screen Sample 5.9) click on the “Dial-up to private network” option and then click Next. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.10
The “Phone Number to Dial” box (see Screen Sample 5.10) prompts the user to type in the actual phone number they will be using for the new connection. The phone number to type in this box is Area Code: 405, Phone number: 4166859 (Do not include any dashes in the phone number). Then select “United States of America [1] for the Country/Region code selection and put a check in the “Use dialing rules” checkbox. Click the Next button.
Screen Sample 5.11 Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Select For all users on the “Connection Availability” section (see Screen Sample 5.11) of the Network Connection Wizard. This option allows all users on this computer to have access to the RAS. Click the Next button.
Screen Sample 5.12
Finally, assign a name to use for the connection (see Screen Sample 5.12). After typing the new connection name in the specified box, click on the “Add a shortcut to my desktop” check box. This option will create an icon on your computer desktop. This enables you to click on the icon whenever you wish to log on to the RAS. After clicking on the Finish button, all the information needed to access the RAS is saved and stored on your computer. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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AACCCCEESSSSIINNGG TTHHEE RRAASS
Screen Sample 5.13
To access the RAS, double click on the shortcut icon found on the desktop (this icon was created when establishing the RAS Connection Setting through the Setup Wizard) (see Screen Sample 5.13). This launches the Connection Box prompt for the RAS. Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Screen Sample 5.14
In the Connection Box prompt (see Screen Sample 5.14), type in the user name and password. All providers accessing the RAS will use the same default user name and password:
Username: Provider
Password: eds123
After typing the user name and password, check the dial-up number to ensure that your computer will dial the correct number. The RAS dial-up phone number is 405-416-6859 Chapter 5: Web/RAS The OHCA Provider Billing And Procedure Manual
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Once the dial-up number is validated, click on the Dial button. This will prompt the computer to attempt connection to the RAS (see Screen Sample 5.15).
Screen Sample 5.15
After connecting and username and password authentication is complete, you will see a prompt in the lower right corner of your desktop verifying the connection (see Screen Sample 5.16).
Screen Sample 5.16
After connecting to the RAS, open a Web browser and type https://192.168.100.163/Oklahoma/Security/logon.xhtml into the browser bar.
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Provider Billing And Procedure Provider Billing And Procedure Manual Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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INTRODUCTION
The following information is intended to provide procedures for submitting claims to the OHCA. For information on what services are covered by the Oklahoma SoonerCare program, please access the agency rules. Rules can be found at www.okhca.org. There are three methods for submitting claims to the OHCA: paper, direct data entry (DDE) via Medicaid on the Web and through 837 batch transactions. Below is a paper-to-electronic conversion table for the different claim-submission types. Please refer to the EDI chapter of this manual for instructions on completing the HIPAA transaction types. Paper DDE HIPAA Transactions
1500
Professional
837P
UB 04
Institutional
837I
ADA 2006
Dental
837D
Pharmacy Drug Claim Form
Pharmacy
NCPDP, version 5.1
Compound Prescription Drug Claim Form
Pharmacy
NCPDP, version 5.1
SECTION A: PAPER CLAIM RECOMMENDATIONS
Claim forms are prepared as follows:
1. Enter complete information with a typewriter, personal computer or ballpoint pen (blue or black ink). Do not use red ink.
2. Provide all required information for every claim line. Do not use ditto marks or the words “same as above.”
3. Verify the accuracy of all information before submitting the claim.
4. Follow the instructions for preparing paper claim forms in this chapter.
5. 1500, UB 04, Drug/Compound and ADA 2006 claim forms are scanned into the OKMMIS. Paper claim forms should be submitted on the original red forms to facilitate the scanning process. This applies to 1500 and UB 04 claim forms. If you submit a copy it must be legible.
6. Mail paper claims to the appropriate mailbox address listed in each claim section.
7. The attachments for a claim should be placed under the identified claim for processing. Do not place the attachment on top of the claim form or it will be associated to previously Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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processed claim. If the attachment is stapled to the claim, place one staple in the upper left corner.
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UB-04, 1500, and ADA 2006 (dental) claim forms can be ordered from a standard form supply company. HP does not distribute supplies of these forms. Drug and Compound prescription claim forms can be downloaded from the OHCA Web site, ordered by contacting the OHCA Call Center or by writing a request to:
HP Form Request P.O. Box 18650 Oklahoma City, OK 73154-0650 Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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SECTION B: 1500, PROFESSIONAL, 837P Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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The 1500 Health Insurance Claim Form (formerly known as the HCFA-1500 and CMS-1500), is the required claim form used by medical providers for professional services, unless otherwise specified. The provider must purchase these forms. This section explains how to complete the paper 1500 claim form.
The form locator chart below indicates which fields are optional, required or required, if applicable. Where necessary, directions applicable to specific provider types are noted. Please mail paper claims to the appropriate mailbox addresses below.
1500 HP Enterprise Services P.O. Box 54740 Oklahoma City, OK 73154
Medicare Crossover (1500 form) HP Enterprise Services P.O. Box 18110 Oklahoma City, OK 73154
Waiver Services HP Enterprise Services P.O. Box 54016 Oklahoma City, OK 73154
HMO Co-Pay/Personal Care Service (individual, not agency) HP Enterprise Services P.O. Box 18500 Oklahoma City, OK 73154
Lab or DME HP Enterprise Services P.O. Box 18430 Oklahoma City, OK 73154
Form Locator 1500 Field Description/Explanation
1
Insurance Location Selection – Enter X for Medicaid. Required.
1a
Insured‟s ID Number – Enter the member‟s SoonerCare identification number. Must be nine digits. Required.
2
Patient‟s Name – (Last name, first name, middle initial) – Enter the member‟s last name, first name and middle initial. Required.
3
Patient‟s Birth Date – Enter the member‟s birth date in MMDDYY format.
Sex – Enter an X in the appropriate box. Optional. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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Form Locator 1500 Field Description/Explanation
4
Insured‟s Name – (Last name, first name, middle initial). Optional.
5
Patient‟s Address - (No., street), CITY, STATE, ZIP CODE, TELEPHONE (Include area code) – Optional.
6
Patient relationship to insured – Optional.
7
Insured‟s Address - (No., street), CITY, STATE, ZIP CODE, TELEPHONE (Include area code) – Optional.
8
Patient Status – Enter X in the appropriate box. Optional.
9
Other Insured‟s Name – Optional.
9a
Other Insured‟s Policy or Group Number – Optional.
9b
Other Insured‟s Date of Birth. Enter the date in MMDDYY format. – Optional.
Sex – Enter X in the appropriate box. Optional.
9c
Employer‟s Name or School Name – Optional.
9d
Insurance Plan Name or Program Name – If other insurance is available, enter the commercial or private insurance plan name. Required, if applicable.
10
Is Patient‟s Condition Related to – Enter X in the appropriate box of each of the three categories. This information is needed to follow-up third party recovery actions. Required, if applicable.
10a
Employment? – (Current or previous) – Check “Yes” or “No” to indicate if the services being billed are employment related. Required, if applicable.
10b
Auto Accident? – Check “Yes” or “No” to indicate if the services being billed are related to an auto accident. Required, if applicable.
Place (State) – Enter the two-character state code. Required, if applicable.
10c
Other Accident? – Check “Yes��� or “No” to indicate if services being billed are related to an accident of another type. Required, if applicable.
10d
Reserved for Local Use – Enter the total dollar amount paid by a primary insurance carrier (for example, 45.00). You do not need to enter a dollar sign ($). Do not put amount paid by Medicare. If the primary insurance carrier did not issue payment, write the words, “Carrier Denied” in this box. A copy of the insurance payment detail or insurance denial must be attached to paper claims. Required, if applicable. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
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Form Locator 1500 Field Description/Explanation
11
Insured‟s Policy Group or FECA Number – If the member has more then one private or commercial insurance, follow directions for form locator 9 in this area. Required, if applicable.
11a
Insured‟s Date of Birth. - Optional.
11b
Employer‟s Name or School Name – Optional.
11c
Insurance Plan Name or Program Name – If other insurance is available, enter the commercial or private insurance plan name. Required, if applicable.
11d
Is There Another Health Benefit Plan – Enter X in the appropriate box. Provide additional third, or more private or commercial insurance information on a separate piece of paper using the directions found in form locator 9. Required, if applicable.
12
Patient‟s or Authorized Person‟s Signature. – Optional.
13
Insured‟s or Authorized Person‟s Signature – Optional.
14
Date of Current Injury, Illness, or Pregnancy – Enter the date in a MMDDYY format of the onset of the illness (day of first symptom) or injury (accident). OB claims must indicate the date the member was first seen for the pregnancy. Required, if applicable, or if form locator 10 has a box checked „Yes‟.
15
If Patient Has Had Same or Similar Illness, Give First Date – Enter date in MMDDYY format. Optional.
16
Date Patient Unable to Work in Current Occupation. – Optional.
17*
Name of Referring Physician or Other Source – Enter the name of the referring physician. Required, if applicable.
17a – 17b
Referring physician‟s ID number.
17a (shaded area)
ID Number of Referring Physician – (small box) Enter the two-character qualifier “1D” to indicate the referring provider‟s ID number is a SoonerCare ID number. Optional. (large box) Enter the 10-character referral number from the Referral Form if the member is enrolled in the SoonerCare Choice or Insure Oklahoma Individual Plan programs. Referral form submission with the claim is not required. Required, if applicable. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 74
Revision Date: April 2011
Version 3.9
Form Locator 1500 Field Description/Explanation
17b (unshaded area)
NPI Number of Referring Physician – Enter the 10-digit National Provider Identifier (NPI) number from the referral form if the member is enrolled in the SoonerCare Choice or Insure Oklahoma Individual Plan programs. Referral form submission with the claim is not required. Optional.
18
Hospitalization Dates Related to Current Service – Enter the requested FROM and TO dates in MMDDYY format. Required, if applicable.
19
Reserved for Local Use – Optional.
20
Outside Lab– Enter X in the appropriate box. Optional
$ CHARGE – Eight-digit numeric field. Optional.
21.1 to 21.4
Diagnosis Nature of Illness or Injury – Enter the diagnosis codes in order of importance: (1) primary; (2) secondary; (3) tertiary; (4) quaternary. These indicators will correspond to the appropriate procedures and be listed in box 24E as 1, 2, 3 or 4. Required, if applicable.
22
SoonerCare Resubmission Code, Original Ref No. – Optional.
23
Prior Authorization Number – The prior authorization (PA) number is not required as the information is systematically verified. Optional.
The CLIA certification number is required to be put in this block when billing for laboratory services. Required, if applicable. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 75
Revision Date: April 2011
Version 3.9
Form Locator 1500 Field Description/Explanation
24 a – j (shaded area)
24a - Enter NDC qualifier “N4” followed by the 11-digit NDC number in 24a. For example: N499999999999.
The NDC should be placed in shaded area above the corresponding HCPCS codes (refer to 24d unshaded area for additional instructions).
Do not enter any spaces or dashes.
24b and 24c – Do not enter any information in these fields.
24d - Enter the unit of measure of “UN” for unit, “F2” for international unit, “ML” for milliliter or “GR” for gram followed by the metric decimal quantity. For example: UN103.50. Do not use spaces or dashes and do not include a description or any information beyond what is indicated above.
24e through 24i – Do not enter any information in these fields.
24j - Enter the nine-digit, one alpha character SoonerCare legacy number in 24j. For example: 100200300A (needs to be fictitious # such as 999999999A)
Required, if applicable.
24 (unshaded area)
Detail service lines should be listed in the unshaded areas of 24a - 24j. A maximum of six service lines are allowed per claim.
24a (unshaded area)
Date of Service – Enter FROM and TO dates in MMDDYY format for the billing period for each service rendered. Six detail lines are allowed per form. Required. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 76
Revision Date: April 2011
Version 3.9
Form Locator 1500 Field Description/Explanation
24b (unshaded area)
Place of service – Enter the place of service code for the place services were rendered. Required.
Place of Service Codes
Code
Description
11
Office
12
Home
20
Urgent care facility
21
Inpatient hospital
22
Outpatient hospital
23
Emergency room
24
Ambulatory surgical center (ASC)
25
Birthing center
26
Military treatment facility
31
Skilled nursing facility (SNF)
32
Nursing facility (NF)
33
Custodial care facility
34
Hospice
41
Ambulance – land
42
Ambulance – air or water
51
Inpatient psychiatric facility
52
Psychiatric facility – partial hospitalization
53
Community mental health center
54
Intermediate care facility for the mentally retarded (ICF/MR)
55
Residential substance abuse treatment facility
56
Psychiatric residential treatment center
61
Comprehensive inpatient rehabilitation facility
62
Comprehensive outpatient rehabilitation facility
65
End-stage renal disease treatment facility
71
State or local public health clinic
72
Rural health clinic (RHC)
81
Independent laboratory
99
Other unlisted facility
24c (unshaded area)
EMG - Emergency indicator. If services are related to an emergency, enter „Y‟. If not, enter „N‟. Optional. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 77
Revision Date: April 2011
Version 3.9
Form Locator 1500 Field Description/Explanation
24d (unshaded area)
Procedures, Services, or Supplies
CPT/HCPCS – Enter the appropriate procedure code for the service rendered. Only one procedure code is billed on each claim form detail line. If your procedure code requires an NDC, enter the appropriate HCPCS code and refer to 24 a-j shaded area for additional instructions. Required.
Modifier – Enter the appropriate modifier, as applicable. Up to four modifiers can be entered for each detail line. Required, if applicable.
24e (unshaded area)
Diagnosis Pointer – Enter the numeric codes (1, 2, 3 or 4), in order of importance, which correspond to the diagnosis code listed in form locator 21. A minimum of one and maximum of four diagnosis code pointers can be entered on each line. Do not enter the full diagnosis code. Required, if applicable.
24f (unshaded area)
$ Charges – Enter the charges for each line item on the claim form. Required.
24g (unshaded area)
Days or Units – Enter the appropriate number of units of services provided for the procedure code. Whole and decimal numbers are acceptable. Required.
24h (unshaded area)
EPSDT Family Plan –If the services being provided are related to an EPSDT visit, enter „Y‟. If not, enter „N‟ or leave blank. If a „Y‟ is entered, the two-digit EPSDT code must be entered in the shaded area above the box. Required, if applicable.
24h (shaded area)
EPSDT Family Plan – If a „Y‟ is entered in the unshaded area of box 24h, enter the two-digit referral type in this box. Appropriate codes are:
NU – Not Available
AV – Available, Not Used
ST – New Services Requested
S2 – Under Treatment
24i – 24j
When entering the rendering provider‟s ID number, only use the shaded areas of 24i – 24j. When entering the Providers NPI number, use the unshaded area of 24j.
24i (shaded area)
ID Qual. – Enter the two-character qualifier, indicating the type of provider number being used for the rendering provider. Enter „1D‟ to indicate the type of provider number used is for Oklahoma SoonerCare. Optional. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 78
Revision Date: April 2011
Version 3.9
Form Locator 1500 Field Description/Explanation
24j (shaded area)
Rendering Provider ID # - Enter the 10-character Oklahoma SoonerCare provider number of the rendering provider. This field can be left blank if billing and rendering numbers, including location code, are identical. Required, if applicable.
24i (unshaded area)
ID Qual – This area is already populated with „NPI,‟ indicating that the provider number listed for the rendering provider is the NPI.
24j (unshaded area)
Rendering Provider ID # - Enter the rendering provider‟s 10-digit NPI. Optional.
25
Federal Tax ID Number – Optional.
26
Patient‟s Account Number – Enter the internal patient tracking number. If the account number is supplied, it will appear on the remittance advice. Optional.
27
Accept Assignment? – Oklahoma SoonerCare only accepts assigned claims. Required.
28
Total Charges– Enter the total of column 24f charges. Each page must have a total. Claims cannot be continued to two or more pages. Required.
29
Amount Paid – Enter the amount paid by the member. Required, if applicable.
30
Balance Due– Field 28, TOTAL CHARGE
BALANCE DUE. Required.
31
Signature of Physician or Supplier– The name of the authorized person, someone designated by the agency or organization and the date the claim was created. A signature stamp is acceptable; however, the statement “Signature on File” is not allowed. Required.
DATE – Enter the date the claim was filed. Be sure not to write any portion of the date outside of the designated box. The date billed must be on or after the date(s) of service. Required.
32
Name and Address of Facility Where Services Were Rendered - Enter the provider‟s name and address if other than home office. Optional.
32a
Enter the 10-digit NPI number of the facility where the services were rendered. Optional.
32b
Enter the two-character qualifier “1D” and 10-character Oklahoma SoonerCare provider ID number of the facility where the services were rendered. No spaces or dashes should be used. Optional. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 79
Revision Date: April 2011
Version 3.9
Form Locator 1500 Field Description/Explanation
33
PHYSICIAN‟S SUPPLIER‟S BILLING NAME, ADDRESS, ZIP CODE, & PHONE # - Enter the name, address, zip code and telephone number of provider requesting payment for services listed on claim form. If the provider furnished the services as part of a group practice organization, enter the name, address, zip code and telephone number of the group practice organization. Required.
33a
Enter the 10-digit NPI number of the physician or group. Optional.
33b
Enter the 10-character Oklahoma SoonerCare provider ID number of the billing provider. No spaces or dashes should be used. Required. (Use of the 1D Medicaid qualifier is optional)
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Use the Professional claim form example and directions below as guides when submitting claims through DDE on Medicaid on the Web. To open the form, choose the „Submit Professional‟ (see Screen Sample 6.1) claim option from the Claims.
NOTE: Medicare denials and crossover claims cannot be billed through the Secure Site using DDE as they are required to be billed on paper.
Screen Sample 6.1 Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 80
Revision Date: April 2011
Version 3.9
Screen Sample 6.2 Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 81
Revision Date: April 2011
Version 3.9
Screen Sample 6.2 continued
DDE Professional Claim Submission Instructions
Billing Information
Provider ID - Provider Number - Your Provider ID should appear in the first box. Verify it is correct. If it is not, you may need to log out and access the correct provider. Required.
Client ID - Enter the member‟s Oklahoma SoonerCare ID number in the Client ID field. (The patient‟s last and first name will auto populate when the member‟s ID number is in the system.) Required.
Patient Account # - The Patient account number will be captured and appear on the remittance advice, if entered into this field. Optional.
Referring physician - Enter the 10-character referral number from the referral form, if the member is enrolled in the SoonerCare Choice program. Required, if applicable. See 1500 form locator 17A.
Service Information
From Date - Enter the from date of service into the From Date field. Required.
To Date - Enter the to date of service into the To Date field. Required.
Expected Delivery Date - Enter the expected delivery date into the Expected Delivery Date field. Required, if applicable. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 82
Revision Date: April 2011
Version 3.9
DDE Professional Claim Submission Instructions
Accident Related To - If claim is related to an accident, select accident type in the Accident Related To field. Required, if applicable.
Diagnosis - Select appropriate diagnosis type in the Diagnosis field by choosing from the drop-down menu. Enter the diagnosis code(s). DO NOT ENTER DECIMALS. Required.
See 1500 form locator 24 for more information.
Charges
Total Charges - Total Charges field is automatically populated.
TPL Amount - Enter the amount paid by any other insurance. If no other insurance is involved or has paid on this claim, leave this field at 0.00. Required, if applicable.
Carrier Denied – If there is other insurance involved and the primary carrier denied the charges, or allowed coverage but did not make a payment (for example: applied to deductible), select ��Yes.‟ If the primary carrier made a payment or if there is no other insurance involved, select „No.��� Required, if applicable.
Detail Information
From DOS - Enter the from date of service in the From DOS field. This will auto-populate from the line detail. Required.
To DOS - Enter the to date of service in the To DOS field. This will auto-populate from the line detail. Required.
POS - Select the place of service code using the drop-down window. Required.
Procedure - Enter the CPT or HCPCS procedure code in the Procedure field. See 1500 form locator 24d for more information. Required.
Modifier - Enter modifier code(s) in the Modifier field(s). Required, if applicable.
Diag. Cross-Ref - Enter the numeric codes (1, 2, 3 or 4), in order of importance, which correspond to the diagnosis code listed in form locator 21. A minimum of one and maximum of four diagnosis code pointers can be entered on each line. Do not enter the full diagnosis code and do not use commas. Required, if applicable.
Units - Enter number of units billed in the Units field. Required.
Charges - Enter the total dollar amount of charges for that specific detail in the Charges field. This action will auto-populate the Total Charges field. Required.
Pregnancy? - If claim is related to a pregnancy, check the Pregnancy? box. Required, if applicable.
Emergency? - If claim is related to an emergency, check the Emergency? box. Required, if applicable. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 83
Revision Date: April 2011
Version 3.9
DDE Professional Claim Submission Instructions
EPSDT - If claim is related to an EPSDT service, select the appropriate referral type from the drop-down list. If nothing is entered, this field will default to „No‟. Required, if applicable.
Rendering Physician – If different from the billing provider number, enter the rendering physician‟s SoonerCare ID number and location code in the Rendering Physician field. This is the rendering provider and is not necessarily a physician. Required, if applicable.
If additional items are to be billed on this submission, click the Add button next to the line item window and repeat process. Click the Remove button to remove a line entry.
Hard Copy Attachments
If a hard-copy attachment is to be added, use the Hard-Copy Attachments arrow at the end of the bar.
Enter an attachment control number as assigned by the provider in the Attachment Control Number field.
The transmission code is entered in the Transmission Code field by clicking on the down arrow, highlighting the appropriate code and clicking on it.
Report type code can be entered into the Report Type field by clicking on the down arrow to make the selection.
Free form text can be entered into the Description field.
Complete form HCA-13 “Paper Attachment to Electronic Claims,” and mail or fax the attachment control number form. See Section F in this chapter for instructions on completing form HCA-13.
Attachment control numbers cannot be made up of special characters or include spaces.
Required, if applicable.
Submit - When finished, click on the Submit button. Required. Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 84
Revision Date: April 2011
Version 3.9
SECTION C: UB 04, INSTITUTIONAL, 837I Chapter 6: Claim Completion The OHCA Provider Billing And Procedure Manual
Library Reference: OKPBPM 85
Revision Date: April 2011
Version 3.9
FFIIEELLDD DDEESSCCRRIIPPTTIIOONNSS FFOORR TTHHEE UUBB--0044 CCLLAAIIMM FFOORRMM
The UB-04 Universal Billing Claim Form, is used to bill for facility services cov